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IBM Patient-Centered Medical Home Pre Launch Briefing
 

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  • IBM Confidential

IBM Patient-Centered Medical Home Pre Launch Briefing IBM Patient-Centered Medical Home Pre Launch Briefing Presentation Transcript

  • Patient-Centered Medical Home What, Why and How? Pre-Launch Briefing May 27, 2009
  • Today’s speakers
    • F. Daniel Duffy, MD, MACP Senior Associate Dean for Academics, University of Oklahoma School of Community Medicine
    • Martin S. Kohn, MD, MS, FACEP, CPE Senior Managing Consultant, IBM Healthcare Strategy and Change Practice
    • Edgar L. Mounib, MBA, MPH Global Healthcare Lead, IBM Institute for Business Value
    Beginning May 28 th , download study at www.ibm.com/healthcare/medicalhome
  • Abstract
    • 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.
    Preface
  • Agenda
    • Introduction
    • The medical home: What is it? What isn’t it?
    • Why should it be done now?
    • How should it be done?
    • Conclusion
    Agenda
  • 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
    Access issues
    • 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."
  • Agenda
    • Introduction
    • The medical home: What is it? What isn’t it?
    • Why should it be done now?
    • How should it be done?
    • Conclusion
    Agenda
    • Patient-centric/Personal PCP
    • PCP-directed medical “team”
    • Whole person orientation
    • Care is coordinated and/or integrated
    • Emphasis on quality and safety
    • Enhanced access
    • Appropriate reimbursement
    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:
      • Consumer responsibility/changing consumer behaviors
      • Reimbursement changes/payment system reform
      • 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
    • 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
    • Individuals
    • Health/wealth planning and management
    • Risk assessment
    • Personal Health Records
    • Connected personal medical devices
    • Trusted clinical information
    • Collaboration tools and trusted sites
    • Benefits selection
    • Provider selection
    Examples of Tools and Services
    • Health coaching
    • Value coaching
    Source: IBM Healthcare and Life Sciences, IBM Institute for Business Value The medical home: What is it? What isn’t it?
  • Agenda
    • Introduction
    • The medical home: What is it? What isn’t it?
    • Why should it be done now?
    • How should it be done?
    • Conclusion
    Agenda
    • Great majority of patients prefer to seek initial care from PCPs rather than specialists, but their unhappiness with their PCP experience is growing.
    • 50 % of patients leave office visits not understanding what the physician told them
    Why PCMH should be done now? The current system does not work and key to its reform is primary care
    • Increasing unsustainability of healthcare system – mounting cost, quality and access issues
      • Impacting economic viability of industries, governments
      • Impacting resources for other investments needed for sustainable economic growth
      • Studies estimate that if every American had access to PCMH, national healthcare expenditures would drop 5.6%, or a savings of at least $67B per year
    • Increasing focus on wellness/prevention – pillars of primary care
      • For example, $1B in the “American Recovery and Reinvestment Act”
    • Can be done now without robust IT infrastructure but not scalable
    Challenge Highlights Why should it be done now? Source: IBM Healthcare and Life Sciences, IBM Institute for Business Value
    • Patient Outcomes/Loyalty
    • Patient Satisfaction/Activation
    • Physician Leadership/Ownership
    • Chronic Disease Management
    • Patient Centered Focus
    • Patient Compliance
    • Employee Productivity
    PCMH helps address systemic cost, quality, and access issues
    • Costs
    • ED Visits PMPY
    • Redundant Tests
    • Unnecessary treatment
    • Hospital stays and readmits PMPY
    • Overall mortality
    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
    • 7300 diabetics
      • Improved compliance
    • Reduced costs 10%
    • BCBS Michigan – new
    • 1,000 physicians
    • Increased payments
    • 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
    • PROVIDERS
    • Primary care associations (333,000 physicians)
    • Associations representing integrated delivery networks, academic medical centers, community hospitals (4,000)
    • PURCHASERS
    • 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
    Legislation Highlights
    • SUPPLIERS
    • Pharmaceutical and medical device companies
    • Solution providers
    • HEALTH PLANS
    • Health plans including Aetna, BC/BS, Cigna, Humana, MVP Health Care and United Healthcare
    • CONSUMER ADVOCATES
    • Unions
    • 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
    • Patient
      • 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
    • Nurse
      • Develop better relationship with patients
      • More involvement with patient care and support (for example, patient education, behavioral change, preventive care, proactive care planning)
    • Pharmacist
      • Participate fully in team-based care (for example, help determine medication and reasonable formularies)
    • Social worker
      • More integrated role to address key patient needs (for example, Medicaid)
    • Hospital
      • 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.
    • Specialist
      • 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
    • Health plan
      • Improved member and employer satisfaction
      • Expend healthcare resources with less waste and greater effectiveness though coordinated evidence-based care.
    • Employer
      • 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.
    • Government
      • 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?
  • Agenda
    • Introduction
    • The medical home: What is it? What isn’t it?
    • Why should it be done now?
    • How should it be done?
    • Conclusion
    Agenda
  • 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
    • Members/patients
    • Initial funding
    • Governance
    • Key metrics
    • Reimbursement
    • Physician practice transformation
    • Technology infrastructure
    • Patient attribution
    • Sustainability
    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?
        • Regular updates?
      • 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
  • Agenda
    • Introduction
    • The medical home: What is it? What isn’t it?
    • Why should it be done now?
    • How should it be done?
    • Conclusion
    Agenda
  • There is no reason to wait to invest in the medical home but invest wisely
    • The medical home is not a “silver bullet” but can become a cornerstone for revamping primary care – an essential component of the overall transformation of U.S. healthcare
    • To support medical homes, we need better clinical evidence, changes in responsibilities of key stakeholders, and a cross-organizational infrastructure to support coordinated care
    • It will not be easy to implement medical homes on a large scale even with the current momentum behind them, given challenges such as funding and the level of change required
    • Fortunately, best practices are emerging for common issues related to planning and implementation
      • When appropriately applied, they can help increase the likelihood of success for an initial rollout and for a sustainable model
    Source: IBM Healthcare and Life Sciences, IBM Institute for Business Value Conclusion
  • For more information, please contact
    • Authors
    • Jim Adams , MBA
    • Executive Director, IBM Center for Healthcare Management
    • E-mail: [email_address]
    • Paul Grundy , MD, MPH, FACOEM, FACPM
    • Global Director of Healthcare Transformation, IBM
    • E-mail: [email_address]
    • Martin S. Kohn , MD, MS, FACEP, CPE
    • Senior Managing Consultant, IBM Healthcare Strategy and Change practice
    • E-mail: [email_address]
    • Edgar L. Mounib , MBA, MPH
    • Global Healthcare Lead, IBM Institute for Business Value
    • E-mail: [email_address]
    • Guest Speaker
    • F. Daniel Duffy , MD, MACP Senior Associate Dean for Academics, University of Oklahoma School of Community Medicine E-mail: [email_address]
    Beginning May 28 th , download study at www.ibm.com/healthcare/medicalhome
  • Thank you!