The patient-centered medical home (PCMH) can serve as a foundation for transformation of the U.S. healthcare system – if appropriately conceived and properly implemented. But it can also suffer from unfettered expectations. This study makes the realistic case for why and how stakeholders can participate in PCMH initiatives, identifies critical issues and makes recommendations for best practices to increase the likelihood of initial success and sustainability.
Despite having many fine care delivery organizations and caregivers, the U.S. healthcare system is badly broken Introduction “ Let there be no doubt ... Healthcare reform cannot wait, it must not wait, and it will not wait another year.” - U.S. President Barack Obama, 24 Feb 2009 Source: IBM Healthcare and Life Sciences, IBM Institute for Business Value High, rapidly rising costs
US$2.5 trillion (17.6% of GDP) will be spent in 2009
US$4.0 trillion (almost 20% of GDP) will be spent in 2015
Highest per capita spend among OECD countries in 2006
48% more than Norway, which spends the third-most
2.4x the OECD average per capita spend
No link between higher costs and quality or safety
98,000 to 195,000 people killed per year by medical mistakes
57,000+ dying from inadequate care
2 million hospital-acquired infections with 90,000 dying per year
4-fold variation in costs with similar quality
Ranked 37 th in overall health system performance by WHO
22 nd in life expectancy, 28 th in infant mortality and 30 th in obesity among the 30 OECD countries
45+ million uninsured
15+ million under-insured, most who are working
Foundational to healthcare transformation is a primary care system that provides comprehensive and timely care
Primary care offers demonstrable benefits that leads to –
Better health outcomes 1
Lower costs 1
Greater equity in health 1
For example, Patients who have a regular primary care provider (PCP) –
Incur about ⅓ less healthcare expenditure 2
Have 19% lower mortality 2
Are 7% more likely to stop smoking 3
Are 12% less likely to be obese 3
Majority of patients prefer initial care from a PCP, rather than a specialist
Introduction Source: 1) B Starfield, Milbank Quarterly, 2003; B Starfield, “The best care is primary care” presented at WONCA 2004; The Future of Family Medicine Study; 2) Franks, Peter and Kevin Fiscella. “Primary Care Physicians and Specialists as Personal Physicians: Health Care Expenditures and Mortality Experience.” Journal of Family Practice. August 1998; 3) Arora, Vineet, Sandeep Gangireddy, Amit Mehrotra, Ranjan Ginde, Megan Tormey, et al. “Ability of hospitalized patients to identify their in-hospital physicians.” Archives ofInternal Medicine. January 26, 2009.
From 1998-2008, 57 % fewer medical school graduates entered family practice residencies 3
In 2004, the median income for primary care physicians was about ½ that of specialists 2
Exacerbating this is a primary care system – the foundation to any healthcare system – that is also broken
PCP shortage is worsening: 35K-44K by 2025
Failure to attract new residents 1
Reimbursement is relatively low and based on quantity 2
Growing levels of frustration
Current primary care practice is geared to treating acute, episodic interventions
Emphasis on triage, not on coordinating care
Minimal communication between providers
Minimal focus on education and self-management
Slow to adopt evidence-based medicine
No tools and support in place such as EMRs
Even with tools, evidenced based medicine is more difficult for PCPs than for specialists because facing more comorbidities or in preventive mode
Generally lower level of support structure (EMR, support staff, etc.)
Challenge Highlights Introduction Source: 1) P.A. Pugno et al., "Results of the 2006 National Resident Matching Program: Family Medicine," Family Medicine 38, no. 9 (2006): 637–646; and T. Bodenheimer, "Primary Care—Will It Survive?" New England Journal of Medicine 355, no. 9 (2006): 861–864; 2) T. Bodenheimer, R.A. Berenson, and P. Rudolf, "The Primary Care–Specialty Income Gap: Why It Matters," Annals of Internal Medicine 146, no. 4 (2007): 301–306; 3) American Academy of Family Physicians. "2008 National Resident Matching Program."
Patient-Centered Medical Home (PCMH) is an approach to deliver comprehensive care, coordinated by a PCP-led extended care team
Brief history of the evolution of the PCMH
1967 : American Academy of Pediatrics defined medical home concepts related to children with special needs
2000-present : AAFP and ACP developed and extended the concept to include care for all patients with chronic illness and patient centeredness
2006-07 : AAFP, AAP, ACP and AOA develop a common definition of “patient-centered medical home” and link PCMH to reform of payment for physicians
Principles of PCMH Technology, Services & Applications to Support the New Collaborative Care Model + + Personal Relationship with a PCP and Care Team Proactive Focus on Health, Care Intervention and Chronic Disease Management “ The Patient-Centered Medical Home (PCMH) provides care that is “accessible, continuous, comprehensive and coordinated and delivered in the context of family and community.” 1 Source: 1) www.medicalhomeinfo.org/join%20statementpdf The medical home: What is it? What isn’t it?
The PCMH concept advocates enhanced access to comprehensive, coordinated, evidence-based, interdisciplinary care Today’s Care Medical Home Care Our patients are those who are registered in our medical home Care is determined by today’s problem and time available today Care is determined by a proactive plan to meet health needs, with or 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 and consultations, and follow-up after ED and hospital Clinic operations center on meeting the doctor’s needs An interdisciplinary team works at the top of our licenses to serve patients My patients are those who make appointments to see me Source: Adapted with permission from F. Daniel Duffy, MD, MACP, Senior Associate Dean for Academics, University of Oklahoma School of Community Medicine The medical home: What is it? What isn’t it?
While other approaches have addressed some PCMH Principles, none have addressed them all Source: IBM Healthcare and Life Sciences, IBM Institute for Business Value The medical home: What is it? What isn’t it? No Partially, if evidence-base used No, still volume driven Potential conflict in motivation Yes for PCPs, unclear for others Appropriate reimbursement No Maybe No No, reduced access Yes Enhanced access Yes, for chronic illnesses Yes, particularly for diseases Indirectly; process targets rather than outcome ones No, reduced utilization rewarded Yes, evidence-based and best practice; improved outcomes rewarded Emphasis on quality and safety Yes Maybe No incentive for coordination No incentive for coordination Yes Care is coordinated and/or integrated Yes No No No Yes Whole person orientation Yes No No No Yes Physician directed medical “team” Yes, for chronic illness Maybe, often led by actors independent of primary care No No Yes Patient centric/ personal physician Org. framework for chronic care mgt and practice improvement Meet specific management targets for chronic disease Meet operational goals with financial incentives Ideally: cost, quality; Actually: control utilization Facilitate partnership between PCP and patient Purpose/focus Chronic care model Disease management Pay for performance Non-integrated managed care PCMH Factor/ Principle Aligned Mixed alignment Not aligned Alignment with PCMH Principle:
Nevertheless, the PCMH model needs additional support
Better clinical content
Evidence-based or personalized health and care/ability to incorporate into practice
Tools to help with correct and complete diagnosis
Changes with and support from other stakeholders since the PCMH model cannot be dropped into the current system for optimal results; examples include:
Alignment, coordination or integration with care delivered by others outside the medical home (e.g. specialists) in other care settings (e.g. ambulatory surgery centers or hospitals); this has been called the “medical neighborhood.”
Policy reform to allow payers to collaborate in designing incentive systems
Universal coverage/coverage decisions
Infrastructure to support PCMH model (IT and other services) targeting the consumer/patient and the clinicians (see next slide)
Source: IBM Healthcare and Life Sciences, IBM Institute for Business Value The medical home: What is it? What isn’t it?
For example, Health Plans or other entities could offer a variety of services or tools both to members and to providers
Tools and resources for virtual interdisciplinary care delivery teams
Tools to support better access to clinical and patient information
Tools to support cost/quality transparency
Tools or services to provide coordinated, integrated care
Tools to enhance access (e-visits, telemedicine)
Tools to streamline administrative processes
Health/wealth planning and management
Personal Health Records
Connected personal medical devices
Trusted clinical information
Collaboration tools and trusted sites
Examples of Tools and Services
Source: IBM Healthcare and Life Sciences, IBM Institute for Business Value The medical home: What is it? What isn’t it?
PCMH helps address systemic cost, quality, and access issues
ED Visits PMPY
Hospital stays and readmits PMPY
Potential impacts of PCMH Why should it be done now? Source: IBM Healthcare and Life Sciences, IBM Institute for Business Value
Why it can be done now? There is a growing evidence that PCMH can work
Others have done it and demonstrated success
Various focused, regional approaches have worked (next slide)
Technology/IT can support and enable
Integrate and synthesize data from multiple sources into actionable information
Ability to disseminate data and standards
Guidelines/best practice work flows/ coordination
Clinicians and patients are using technology today
Momentum and public awareness of need for change
Increasing awareness that change is inevitable
Dichotomy between cost and outcomes
Why should it be done now? If the U.S. is serious about closing the quality chasm, it will need a strong primary care system, which requires fundamentally reforming provider payment, encouraging all patients to enroll in a patient-centered medical home , and supporting physician practices that serve as medical homes with the information technology and technical assistance for redesigning care processes. - Karen Davis, President, Commonwealth Fund Source: IBM Healthcare and Life Sciences, IBM Institute for Business Value
To date, more than 30 PCMH pilots have been initiated and many are demonstrating cost, quality and access improvements Multi-Payer pilot discussions/activity Identified pilot activity No identified pilot activity
“ Voice of Detroit Initiative” – 25K uninsured
Reduced ED use by over 60%.
Reduced costs from uncompensated care by 42%
Among homeless and substance abuse patients, reduced hospitalizations by 55% and reduced cost of care by 24%
Community Care of NC (CCNC) – 785K Medicaid enrollees
Asthma: 34% lower hospital admission rate; 8% lower ED rate; average episode cost for enrolled children was 24% lower; 93% received appropriate inhaled steroid
Diabetes: 15% increase in quality measures
Program savings: 13% lower ED rate; ~$150M in last fiscal year
BCBS of North Dakota - Diabetes care management
Reduced hospital admissions by 6%, reduced ED visits by 24%
Improved patient satisfaction with care,
Program savings of $1213 per patient ($233,000 total) (2006)
Geisinger Health System – Integrated delivery network in Western Pennsylvania
Reduced hospital admissions by 20%
Reported medical cost savings of 7%
Why should it be done now?
Horizon BCBS New Jersey
Reduced costs 10%
BCBS Michigan – new
2 million patients
$30 million in incentives
Source: Patient Centered Primary Care Collaborative ( http://pcpcc.net/ ), IBM Healthcare and Life Sciences, IBM Institute for Business Value RI
PCMH is also drawing support from key stakeholder groups and is being bolstered by lawmakers
Primary care associations (333,000 physicians)
Associations representing integrated delivery networks, academic medical centers, community hospitals (4,000)
Most Fortune 500 (100M lives)
Federal, State Governments
Medicare : Demonstrations from H.R. 6111 – “Tax Relief and Health Care Act”; more Medicare implementations
Medicaid : NC, MO, LA already planning and implementing; Transformation Grants
S-CHIP : Language to encourage transition to medical home model
Health IT Legislation and SGR Reform : Medical home language, encouragement for PCPs to adopt support systems
Quality Improvement Organization 9th Scope of Work Language
Medicaid Transformation Grants
Pharmaceutical and medical device companies
Health plans including Aetna, BC/BS, Cigna, Humana, MVP Health Care and United Healthcare
Special interest groups
Supporters of the Patient Centered Primary Care Collaborative Why should it be done now? Source: Patient Centered Primary Care Collaborative ( http://pcpcc.net/ ), IBM Healthcare and Life Sciences, IBM Institute for Business Value
There are demonstrable benefits to the Patient, as well as to caregivers who work at the “top of license” in an integrated team
Help from a trusted resource to navigate healthcare system
Empowered to make better-informed healthcare decisions
Receive safe, effective care with compassion
Achieve healthier outcomes collaboratively with extended care delivery team
Improved relationship with PCP, health plan
Primary care provider
Redefine patient relationship to deliver more comprehensive, coordinated care
Fair compensation for PCMH services, as well as rewards for improved clinical outcomes
Through a shift in incentives, able to more effectively provide wellness and preventative care
Better supported to deliver quality care to patients
Develop better relationship with patients
More involvement with patient care and support (for example, patient education, behavioral change, preventive care, proactive care planning)
Participate fully in team-based care (for example, help determine medication and reasonable formularies)
More integrated role to address key patient needs (for example, Medicaid)
Serve PCMH patients whose conditions may not be as severe as non-PCMH patients
Potentially reduce admissions from patients who cannot pay
Potentially reduce number of re-admissions, for which there may no or reduced payment.
Receive higher quality referrals, with more complete documentation
Improved focus on area of expertise without having to assume management of patient’s primary care
Opportunity to offset income losses by participating in financial incentives for coordination and quality (for example, telephone consultations).
Potential benefits by stakeholder Source: IBM Healthcare and Life Sciences, IBM Institute for Business Value Why should it be done now?
PCMH also offers potential benefits to Payers, the Life Sciences, and Governments
Improved member and employer satisfaction
Expend healthcare resources with less waste and greater effectiveness though coordinated evidence-based care.
Purchase healthcare based on value and potentially see medical cost savings
Maintaining more present and productive workforce, in part, through improved wellness and prevention.
Pharmaceutical and other life sciences
Improved appropriateness of and compliance with therapeutics
Enhanced pharmacovigilance of products, post clinical trials.
Potential to improve care quality, reduce wasteful healthcare expenditures
Address frustration with the current uncoordinated and impersonal system.
Communities and society
Potential for a healthier, more productive citizenry
Potential to allocate dollars so that they have greater return.
Potential benefits by stakeholder (continued) Source: IBM Healthcare and Life Sciences, IBM Institute for Business Value Why should it be done now?
When correctly implementing a PCMH pilot, key steps must be taken to help ensure consistent alignment with the problem at hand What is the problem What is the problem How should it be done? Source: IBM Healthcare and Life Sciences, IBM Institute for Business Value What is the Problem ?
What cost/quality/ access issue(s) are you targeting?
Near, long term?
What are your vision, guiding principles?
What are Common Implementation Issues ?
Incentives to participate
Physician practice transformation
What are the Best Practices ?
Who else has addressed our problem?
What can we learn from them to address our key implementation issues?
Is Our Approach Consistently Aligned With Problem We are Trying to Solve?
Do you have…
An appropriate governance structure with the right participants?
An agreed-upon project plan and strong project manager?
Capabilities to support the patient cohort?
Metrics to measure alignment with and progress toward original objectives?
All team members collaboratively contribute at the “top of their licenses,” helping the overall practice operate more efficiently and effectively Registration, MH assignment, billing, contracting, compliance with contract Access to appointments, non-visit advice and help Clinical Preventive services Acute Care, ER and UCC Management Patient Activation & Behavior Change Social & Mental Health Services Medication Monitoring Diagnosis and Dr ug Management Specialists High-ris k Care Management 0% 25% 50% 75% 100% Volume of services Source: Adapted with permission by IBM from F. Daniel Duffy, MD, MACP, Senior Associate Dean for Academics, University of Oklahoma School of Community Medicine How should it be done? Sample medical home PCP practice Sample Implementation Issue Medical Home Multidisciplinary Team Clerical Nursing Physician, PA, NP Social Work Pharmacy & Nursing
Key Metrics – Measurement and evaluation processes are critical because of their effects on incentives, resulting organizational learning and other factors
To date, medical home efforts have used a combination of the following types of key metrics:
Costs: Impacted by things like the types and number of patients, as well as duration of initiative
Process of care: Include appropriate screening for traditional conditions, alignment with NCQA accreditation measures or targeted conditions that are endemic to local population
Outcomes of care: Measures change in health for a patient or a cohort, such as individual conditions and patient compliance (e.g., tracking HbA1c) or utilization (e.g., ER visits)
Service: Have focused on operational aspects, such as the wait until the next appointment
Patient and caregiver satisfaction: Demonstrates the PCMH initiative’s commitment to quality and in improvements by assessing the satisfaction of patients and clinicians
Coordination of care: Are more innovative but require a sophisticated tracking system
University of Oklahoma is developing a set of measures that accounts for the rapidity of referrals and getting the referral and includes quality and process measures
Sample assessment questions for include the following:
Is there an agreed-upon set of metrics that are aligned with your original problem?
Pilot phase? Full roll out?
Is the data needed easy to collect, analyze, report, and act upon?
How should it be done? Source: IBM Healthcare and Life Sciences, IBM Institute for Business Value Sample Implementation Issue