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

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

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

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.

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

Introduction

The medical home: What is it? What isn’t it?

Why should it be done now?

How should it be done?

Conclusion

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

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

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.

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

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."

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

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.)

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

Introduction

The medical home: What is it? What isn’t it?

Why should it be done now?

How should it be done?

Conclusion

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?

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

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

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?

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)

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?

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

Health coaching

Value coaching

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

Introduction

The medical home: What is it? What isn’t it?

Why should it be done now?

How should it be done?

Conclusion

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

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

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

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

Patient Outcomes/Loyalty

Patient Satisfaction/Activation

Physician Leadership/Ownership

Chronic Disease Management

Patient Centered Focus

Patient Compliance

Employee Productivity

Costs

ED Visits PMPY

Redundant Tests

Unnecessary treatment

Hospital stays and readmits PMPY

Overall mortality

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

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

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

“ 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%

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

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

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

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

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?

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).

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?

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.

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

Introduction

The medical home: What is it? What isn’t it?

Why should it be done now?

How should it be done?

Conclusion

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?

What cost/quality/ access issue(s) are you targeting?

Near, long term?

What are your vision, guiding principles?

Incentives to participate

Members/patients

Initial funding

Governance

Key metrics

Reimbursement

Physician practice transformation

Technology infrastructure

Patient attribution

Sustainability

Who else has addressed our problem?

What can we learn from them to address our key implementation issues?

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

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?

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

Introduction

The medical home: What is it? What isn’t it?

Why should it be done now?

How should it be done?

Conclusion

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

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

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

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]

Thank you!