Discuss this from the perspective of the integrator
What is PCMH? By definition, PCMH is an enhanced primary-care model that delivers comprehensive and timely care to patients, emphasizing the central role of teamwork and engagement between caregivers and patients
University of Utah 2012Paul Grundy, MD, MPH, FACOEM, FACPMIBM Director Healthcare TransformationPresident Patient Centered Primary Care Collaborative Trip to Denmark July 10 2009 Copyright 2011 by IBM1
In Alaska in Utah –PCMH CARE by Design The “foundation” has achieved startling efficiencies is the most advanced locations: Emergency room use has been reduced by 50 percent, Hospital admissions by 53 percent, Specialty care visits by 65 percent.These efficiencies, in turn, have clearly saved money 60% Reduction in Complications of Diabetics
And Patients Not Shortchanged Patients are virtually guaranteed a doctor’s appointment on the day they request it, and their calls are answered quickly, usually within 30 seconds. The percentage of children receiving high-quality care for asthma has soared from 35 percent to 85 percent, The percentage of infants receiving needed immunizations by age 2 has risen above 90 percent, The percentage of diabetics with blood sugar under control ranks in the top 10 percentile of a standard national benchmark, and customer and Employee satisfaction rates top 90%.
THE PCMH foundation of the Triple Aim Readiness, Experience of Care, Population Health, Cost Per Population Capita Health Cost The System Integrator System Integrator Patient Productivity Creates a partnership across the medical Experience neighborhood Drives PCMH primary care redesign Offers a utility for population health and 28 financial management Copyright 2011 by IBM
Why Innovate? Affordability The elephant in the room 166% 118% 2001 2009 2019Costs continue their upward climb with employers paying much of the tab - Employer Cost - Employee Payroll Contributions - Employee Out of Pocket Expenses Source: Dr. Martin Sepulveda Copyright 2011 by IBM 5
USA 2012 Ogden Utah SLC UtahThe Cause? Mostly due to unregulated fee-for-service payments and an over reliance onrescue/specialty care. This is stark evidence that the U.S. health care Industry has beenfailing us for years “Commonly cited causes for the nations poor performance are not toblame - it is the failure of the delivery system !!”- Unaccountable Care Organizations 20 *Source: Peter A. Muennig and Sherry A. Glied Health Affairs Oct. 7, 2010 Copyright 2011 by IBM
VA Outranks Private Sector in Health Care Patient Satisfaction Thirteen Year Cumulative Percent Change in Cost VHA Cost Per Patient Total Medical Care Obligations per Total Unique Patients (including non-Veterans)Average Medicare Payment Per EnrolleeMedicare Program Benefits per Enrollee Consumer Price Index Bureau of Labor Statistics All Urban Consumers 11
Montana Governor Schweitzer opens new stateemployee Medical Home primary care clinic
Why would hospitals perform unnecessary heart surgery? Because it pays!!.looked at cardiology procedures done. They found that 43 percent shouldnot have happened Washington Post -Sarah Kliff on August 7, 2012 at 9:56 amNew York Times Sept 2012: PuttingProfits Before Patients ---disturbing pattern of superfluous heart surgeries that putpatients lives at risk without any evidence of valueAugust 27, 2012, New York, TimesOver treatment Is Taking a Harmful Costly TollBy TARA PARKER-POPEcosting the nation’s health care system at least $210 billion Somebody has to do something, and its just incredibly pathetic that it has to be us.
Build your own corporate PCMH Per Employee Per Month $805 $804 Health Costs $765 Post Implementation Actual client data: Midwest Hospital with 12,135 employees 1 year self- $569 funded for group health Copyright 2011 by IBM 17
WellPoints New Hire - What at Is Watson? Copyright 2011 by IBM 19
Practice Transformation Away Episode of Care Flow Design Chronic Preventive Disease Medication Medicine Monitoring Refills Acute Care Test Results DOCTORHealthcare Support Team Case Behavioral Medical Nursing Manager Health Assistants Source: Southcentral Foundation, Anchorage AK
Healthcare Industry is beset with some of the most complexinformation challenges we collectively face –In fact the currentstructure has failed us. Medical information is doubling every 5 years, much of which is unstructured 81% of physicians report spending 5 hours or less per month reading medical journals Source: International Journal of Circumpolar Health, DoctorDirectory.com, Institute for Medicine"
PCMH Parallel Team Flow Design The glue is data – just like banking Chronic Acute Point of Chronic Disease Care Care Testing Disease Monitoring Compliance Acute Barriers Test Preventive MentalMedication Results Medicine Health Refills ComplaintHealthcare Support Case Medical Behavioral Team Clinician Manager Provider Assistants Health Source: Southcentral Foundation, Anchorage AK
Benefit Redesign - Patient EngagementDifferent Strategies for Different Healthcare Spend Segments Those with severe, acute illness or injuries % Total Healthcare Spend Those with chronic illness Those who are well or think they are well % of Members 21 21
Payment reform requires more than one method, you have dials, adjust them!!! “fee for health” “fee for outcome” “fee for process” “fee for belonging “fee for service” “fee for satisfaction” Copyright 2011 by IBM 32
FEHB Program Carrier Letter All Carriers U.S. Office of Personnel Management-Federal Employee Insurance Operations -Letter No. 2012-09 We are reinforcing our support for patient centered medical homes (PCMH). We are again calling for to increase FEHBP members’ access to primary care providers who have adopted the principles of the medical home. 29 March 2012
OPM $39 Billion Book with Accountable Care Patient at the Center 24-7 clinician phone response Pre-visit planning and after-visit follow-up for care management. Provide open scheduling. Offer patient self-management Provide care management and support. coordination by specially-trained team members. Provide a visit summary to the patient following each visit. Use an EHR with decision support. Maintain a summary-of-care Use CPOE for all orders, test tracking, record for patient transitions. and follow-up. Email consultations. Medication reconciliation for every visit. Telephone consultations. Prescription drug decision support. The development of care plans. Implement e-prescribing. Performance outcome measures. Copyright 2011 by IBM 31
Multi-state and National exchange - Section 1334 of the ACA OPM base of the multi-state exchange and the national exchange -- everyone is so focused on the states they miss the fact that OPM under the law is the agent for the other two exchanges it is built on this carrier letter. OPM requirements are found in Section 1334 of the ACA for OPM to contract with health insurers to offer multi-state qualified health plans ("MSQHPs") to the individual and small-group markets. The contours of OPMs implementation of the MSQHP contracts will have a significant impact on health insurance issuers that will participate in the state-based "American Health Benefit Exchanges" ("Exchanges") for the individual and small-group markets.
CPCI Five Functions/Framework ForComprehensive Primary Care Risk stratified care management Access and continuity (24/7 with EMR) Planned care for chronic conditions and preventive care (proactive management) Patient and caregiver engagement Coordination of care across the medical neighborhood Payment includes $20.80PMPM26
The World Changed Jan 27th 2012 Insurer WellPoint to revamp primary care pay January 27, 2012 The Associated Press An Rx? Pay More to Family Doctors WellPoint to invest 1 Billion in primary care transformation. “Patient Centered Medical Home” model emphasized in Anthem initiative UNITED HC see you 10 raise you Conversation with OPM Yesterday - Ways and Means and what that means
The Foundation: Patient Centered Primary CareWellPoint strategy will drive transformation to a patient-centered care model by aligningeconomic incentives and giving primary care physicians the tools they need to thrive in a value-based reimbursement environment. Benefit design Expanded Aligning care Exchange of tied to access through management meaningful measurable innovation with the information behavior delivery system changes and outcomes Four Foundational Pillars
WellPoint - Patient Centered Primary Care (PC2)Strategy – A bold and aggressive plan This strategy represents an aggressive and fundamental shift in how we interact with and engage primary care physicians on all levels: clinically, contractually, operationally and culturally.
PCMH Preliminary Year 2 Highlights In SeptIssue Health affairs 2012 18% decrease in acute IP admissions/1000, COLORADO compared to 18% increase in control group 15% decrease in total ER visits/1000, compared to 4% increase in control group Specialty visits/1000 remained around flat compared to 10% increase in control group NEW HAMPSHIRE Overall Return on Investment estimates ranged between 2.5:1 and 4.5:1 New York
NCQA PCMH Recognition Pioneered by Univ of Utah
OUR Patient needs A long-term comprehensive relationship with a Personal Physician empowered with the right tools and linked to their care team. Copyright 2011 by IBM8
The Joint Principles: Patient Centered Medical Home Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, and 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 Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or arranging care with other qualified professionals Care is coordinated and integrated across all elements of the complex healthcare community- coordination is enabled by registries, information technology, and health information exchanges 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 voluntary engagement in performance measurement and improvement Enhanced access to care is available - systems such as open scheduling, expanded hours, and new communication paths between patients, their personal physician, and practice staff are used Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home- providers and employers work together to achieve payment reform Copyright 2011 by IBM 9
From Episode of Care to Population Management atthe Personal level Centered on the Patient + + = Instrumented Interconnected Intelligent An opportunity to think and act in new ways—Not master-builder but Master plan DATA DRIVEN OUTCOMES based!!
Defining the Care Centered on Patient Superb Access to Care Team Care Patient Engagement in Care Patient Feedback Clinical Information Systems, Registry Publicly Available Information Care Coordination Copyright 2011 by IBM 30
Smarter Healthcare36.3% Drop in hospital days32.2% Drop in ER use12.8% Increase Chronic Medication use-9.6% Total cost (Mayo Zero cost increase)10.5% Inpatient specialty care costs down18.9% Ancillary costs down15.0% Outpatient specialty downOutcomes of Implementing Patient Centered Medical HomeInterventions: A Review of the Evidence from Prospective EvaluationStudies in the US K. Grumbach & P. Grundy, November 16 th 2010 Copyright 2011 by IBM 13
PCMH at CareMore a hospitalization rate 24 percent below average hospital stays 38 percent shorter an amputation rate among diabetics 60 percent lower than average most remarkable of all, these improved outcomes have come without increased total cost Would Zsa zsa still have a leg to stand on your MOM?? Copyright 2011 by IBM 14
10 Trained & Engaged Leadership 9 8 Template Coordination of the of care future 7 5 6Building Blocks of High-Performing PromptPrimary Care Population ContinuityApril 2012 Center For Excellence in Primary Care access to Management of care care 1 2 3 4 Shared Data-driven Empanelment Team- Vision & & panel size Improvement based Goals management care
Trajectory to Value Based Purchasing:Achieving Real Care Coordination andOutcome Measurement Registry Copyright 2011 by IBM 34
PCMH in Action Vermont “Blueprint” model A Coordinated Hospitals Health System Community Care Team PCMH Nurse Coordinator Social Workers Health ITSpecialists Dieticians Framework Community Health Workers Care Coordinators Global Information PCMH Framework Public Health Prevention Public Health HEALTH WELLNESS Evaluation Prevention Framework Operations Copyright 2011 by IBM 35
Horizon BCBS NJ Patient-Centered Medical Homes Drive Quality and Cost Improvements 152 physicians at 22 practices within ten counties.Quality Measures 8% higher rate in improved diabetes control (HbA1c) 6% higher rate in breast cancer screening 6% higher rate in cervical cancer screeningCost and Utilization Indicators 10% lower cost of care (per member per month) 26% lower rate in er visits 25% lower rate in readmissions 21% lower rate in inpatient admissions 10 April 2012
Don’t handle your care needs in a BAD MEDICAL NEIGHBORHOOD!!Unaccountable care, lack of organization, DO NOT GO THERE ALONE !!Be wise when you pay for care, KNOW WHAT YOU BUY!! Copyright 2011 by IBM 21
BCBS MI 2670 physician (BIG study)WAYS AND MEANS 2010 2011 Adults (18-64) ER visits -6.6% -9.9% Primary care sensitive ER Visits -7.0% -11.4% Ambulatory care sensitive Hospitalizations (per 1,000) -11.1% -22.0% BCBS MA 6% decreased cost (NEJM) Copyright 2011 by IBM 12
Cost of Commercial lives Least Expensive Most Expensive Ogden, UT $2,623 Anderson, IN $7,231 Dubuque, IA $2,719 Punta Gorda, FL $7,168 McAllen TX $2,950 Racine, WI $6,528 Providence $6,367 Naples, FL $6,312 Ocean City, NJ $6,128 Copyright 2011 by IBM 22
Coordination -- we do NOT know how to play as a team“We dont have a health care delivery system in this country. Wehave an expensive plethora of uncoordinated, unlinked, microsystems, each performing in ways that too often create sub-optimalperformance, both for the overall health care infrastructure and forindividual patients." George Halvorson, from “Healthcare Reform Now” Copyright 2011 by IBM 26
Benefit Plan Paid Claims – Calendar Year 2010 % TotalHealthcare Spend Ten percent of the population consumes 66% of the total spend (members with > $10,000 in expenses) 49% of the population consumes only 4% of the total spend (each spends < $1,000) % of Members 49
OPM requesting PCMH level care OPM Technical guidance 19 April 2012 requires all Plans to Submit: Criteria for PCMH recognition Percent and listing of all plans that have reached certification Number of covered lives in PCMH Recommended Provider payment incentives Plan to invite Patient into PCMH level care Quality outcomes associated with PCMH Inclusion in all CMS and state PCMH initiatives efforts (like CPCi , MAPC).
CMS Plus most other buyers11% CMS Shift in payment away from FFSto other dials.CMS Bundling!! CMS Advanced Primary CareWellpoint PCMH, BCBS Hawaii no new FFS $$ Copyright 2011 by IBM 33
If you scan the world for value based healthcare, you will find acommon element: a relationship-based team with a projectmanager! A comprehensivist that can command and controlin an accountable system. So simple! So much! Copyright 2011 by IBM 29
PCMH level Clinic Competitive Advantage Annual per employee group health savings Advantage grows dramatically over time $9,420 per employee $7,264 per employee $5,486 per Expected employee $4,025 per employee $2,830 per employee Expected with ClinicYears of PCMH implementation Savings per employee Copyright 2011 by IBM 18
Enhancing Health and the Patient ExperienceMedical Home Model Team-Based Care that is Healthcare DeliveryAccountable Population Access to Care Health Advanced IT Patient is the center Patient-Centered Systems of the Care Medical Home Decision Refocused Support Tools Medical Training Patient & Physician Feedback Model adapted from the Copyright 2011 by IBM 39 NNMC Medical Home
PATIENT CENTERED MEDICAL HOME: VHA Patient Aligned Care Team Replaces episodic care based on illness and patientcomplaints with coordinated care and a long term healing relationship Copyright 2011 by IBM 40
Individual Behaviors withPayment and Benefit Reforms Fee for Service Bundled Payments Shared Savings Global Capitation Tiered networks Tiered networks Tiered networks GatekeeperBenefit Plan Steerage Member obligations Autonomy Autonomy “Attribution” “Assignment”Patient choice of providers Well understood by payers Complex Extremely complex Well understood by some and providers providers and payersAdministrative complexity Minimal Moderate Substantial SubstantialRisk to ProvidersAbility of providers to No incentive Substantial within the bundle Uncertain Substantial acrossmanage utilization andoutcomes Minimal at best Built into budget for bundle Timing issue SupportedSupport for caremanagement Substantial, even with Controlled Substantially controlled Can be totally controlledRisk to payers external UM within the cap budget 57
According to the study by NEHI, U.S. health care costs are wildly out of alignment with the actual determinants of health. About 50 percent of health status isdetermined by diet, exercise, smoking, stress and safety—or lifestyle choices and available options; 20 percent by exposure to environmental toxins; 20percent by genetic predisposition; and just 10 percent by access to health care. Yet the vast majority—88 percent—of Americans’ health dollars are spent onaccess to care and treatment, with just four percent spent on lifestyle options and choices and eight percent on environmental and genetic factors. Thismismatch results in higher and higher costs for less and less health benefit. While many Americans believe that our health care system is the best in theworld, the fact is that our health relative to other nations, which spend much less per capita, is slipping, even for survival rates among adults age 45–55.
Reinventing Medicaid findings are Outstanding Oklahomas patient-centered medical home initiative has reduced Medicaid costs $29 per patient per year from 2008 to 2010. Moreover, use of evidence-based primary care, including screening for breast and cervical cancer, increased. The Colorado initiative expanded access to care. Before the initiative, only 20 percent of pediatricians in the state accepted Medicaid; as of 2010, 96 percent and did and at a lower cost to the state. Vermont, inpatient care use and related per-person per-month costs decreased 21 percent and 22 percent, respectively, from July 2008 to October 2010. ER use and related per-person per-month costs decreased 31 percent and 36 percent, respectively. Patient Centered Medical Home in Washington in State Acute care spending there was 18 percent below the national average. Inpatient stays per beneficiary were 35 percent below the national average.The Bottom Line in MedicaidPCMH starting to show an impact in access to care, quality, and cost control . Source -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results," Health Affairs, July 2011 30(7):1325–34. Copyright 2011 by IBM 41
PCMH is non-political – the right POVfor delivery transformation“We never abandoned advocating newModels of care. We’ve long pushed folksto realize that Delivery reform is the key.”The patient-centered medical home iscore. “We included the attached chapter on PCMH in our book. and have a new publication on ACOs coming out in January.” Copyright 2011 by IBM 44
Total Hospital and Physician Costs for Select Surgeries – International Comparisons US US CAN FRA GER NETH SPA SWIZ UK (95th (avg) %ile)Appen- $3,810 $2,795 $3,285 $4,624 $2,537 $2,570 $3,476 $13,123 $25,344dectomyHipReplace- $10,753 $12,629 $15,329 $12,737 $9,327 $6,683 $9,637 $34,454 $75,369mentBypass $22,212 $16,325 $27,237 $19,180 $15,802 $11,618 $13,998 $59,770 $126,182Surgery Source Int’l Federation of Health Plans:2010 Healthcare Price Report Copyright 2011 by IBM 25
Patients love to see meaningful information aboutthemselves and it takes IT tools to If you give patients educational materials with their name on it and with their data analyzed in it, they will read it, pour over it and discuss it with you. If you tear off a generic sheet and give it to them, it often goes in the waste basket. If you give patients an analysis of their health risk AND if you include a “what if” scenario, i.e., what will their health risk be if they make a change; you can prove it to them “If you the healer make a change, it will make a difference to your patient.” Copyright 2011 by IBM 43
If we truly want to understand costs and where they can be reducedwithout compromising outcomes, we need to aggregate costs aroundthe patient. (need a place to do that – that is PCMH)The way care is currently organized leads to redundant administrativecosts, unnecessary and expensive delays in diagnosis and treatment,and unproductive time for physicians.A system integrator a place where data is aggregated, understood andheld accountable at the level of the individual patient -- THAT ISPCMH.In fact, cost reduction will often be associated with better outcomes. The Big Idea: How to Solve the Cost Crisis in Health Care, Robert S. Kaplan and Michael E. Porter Sept 2011 Harvard Review Copyright 2011 by IBM 6
ACO and the Principles of the PCMHWhether building a community-wide ACO or a solo primary care practice,adherence to guiding PRINCIPLES provides the foundation. Through the PCMHJoint Principles, we (the buyers and providers) have agreed to change ourcovenant with one another. The Joint Principles of the PCMH have been agreedon by those who deliver comprehensive care (the primary care providers) andtheir specialist colleagues. For Accountable Care to achieve its goals, successfulorganizations will NEED a foundation in these principles. As a buyer, I want to be assured that the foundation - the principles - are in place: a personal relationship with a healer, improved access, care that is coordinated, integrated and comprehensive. Copyright 2011 by IBM 10
PCMH is the patients view from the bottom up. The kind ofcare they want: relationship, accessible, coordinated From the System view it is ACOOr, like the Euro tunnel you can start on one side buildingPCMH and the other side ACO, but somewhere you haveto meet in the middle, where care is delivered- centered onthe needs of the patient. Copyright 2011 by IBM 11
Cost per Case $1548 savings per Comparison case after contract implementation $2085 savings per $3105 savings per case after contract case after contract implementation implementation Savings Gap Savings Gap Savings Gap $1231 savings per case after contract implementation Savings Gap Copyright 2011 by IBM16
Population management !! Accountability !!Who was theShooter’s Doctor?Away fromEpisodes of Care -FFS Copyright 2011 by IBM 3
Parachute use to prevent death and majortrauma related to gravitational challenge;systematic review of randomised controlledtrials. Here is None _ Why ?? Smith GC, Pell JP. BMJ 327:1459-1461; 2003.