Overview of the Patient Centered Medical Home


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  • FFM: Base case = 5 physicians; initial purchase of equipment & supplies (capital costs); new personnel/training; lost productivity, EMR transition
  • Overview of the Patient Centered Medical Home

    1. 1. Overview of the Patient Centered Medical Home (PCMH) Neil Kirschner, Ph.D Senior Associate, Regulatory and Insurer Affairs Division of Government Affairs & Public Policy American College of Physicians Email: nkirschner@acponline.org Phone: 202-261-4535 Presentation to the Maryland Chapter American College of Physicians November 20, 2008
    2. 2. Need for a New Healthcare Delivery Model <ul><li>Increasing costs </li></ul><ul><ul><li>Healthcare costs are growing faster than the economy and the cost of care is becoming difficult for employers, government and individuals to meet. </li></ul></ul><ul><li>Need to improve quality </li></ul><ul><ul><li>Patients receiving recommended treatment 55 % of the time </li></ul></ul><ul><ul><li>Poor U.S. performance on healthcare benchmarks compared to other developed countries despite spending more. </li></ul></ul><ul><li>Regional variation </li></ul><ul><ul><li>Healthcare cost and quality vary substantially among geographic regions. Little relationship between cost and quality. </li></ul></ul>
    3. 3. Need for a New Healthcare Delivery Model <ul><li>Inadequate response to chronic care needs </li></ul><ul><ul><li>Increasingly aging and chronically ill population with payment system that doesn’t recognize services found necessary for essential care e.g. care coordination, evidence-based population management, disease self management </li></ul></ul><ul><li>Decreased Interest in Primary Care </li></ul><ul><ul><li>The number of new students entering into primary care is decreasing and physicians who have chosen the field are disproportionately leaving compared to other specialties. </li></ul></ul><ul><ul><li>Both domestic and international data indicating that higher proportion of primary care physicians related to higher healthcare quality and lower costs. </li></ul></ul>
    4. 4. A Joint Proposed Solution The Patient-Centered Medical Home (PCMH) <ul><ul><li>Modern “medical home” concept originally in Pediatric literature in the 1960’s—a central source of care for “Special Needs” children. </li></ul></ul><ul><ul><li>AAFP—Future of Family Medicine Project (2004) “Personal Medical Home” </li></ul></ul><ul><ul><li>ACP—Advanced Medical Home (2006) </li></ul></ul><ul><ul><li>Key elements of a PCMH are described in a March 2007 joint statement of principles from ACP, AAFP, AAP and AOA. Often referred to as the “Joint Principles”. </li></ul></ul><ul><ul><li>Nexus of patient-centered care, primary care and chronic care model concepts </li></ul></ul>
    5. 5. The Patient-Centered Medical Home <ul><li>Redesigns clinical delivery and payment to facilitate </li></ul><ul><ul><li>Patient-centered, longitudinal, coordinated care delivered by a “recognized” practice with a personal physician </li></ul></ul><ul><ul><li>Who accepts responsibility for the patient’s “ whole person ” </li></ul></ul><ul><ul><li>Who acts in partnership with patients and in collaboration with multidisciplinary teams (nurses, physician specialists, health educators, pharmacists) </li></ul></ul><ul><ul><li>Who uses practice level systems to improve access and communication, care integration, patient safety and outcomes </li></ul></ul><ul><ul><li>Who accepts accountability for care provided through on-going performance measurement and quality improvement. </li></ul></ul>
    6. 6. Professional Societies Endorsing “Principles” <ul><li>American Academy of Hospice & Palliative Medicine </li></ul><ul><li>American Academy of Neurology </li></ul><ul><li>American Academy of Pediatrics </li></ul><ul><li>American Academy of Family Physicians </li></ul><ul><li>American College of Cardiology* </li></ul><ul><li>American College of Chest Physicians* </li></ul><ul><li>American College of Osteopathic Family Physicians </li></ul><ul><li>American College of Osteopathic Internists </li></ul><ul><li>American College of Physicians </li></ul><ul><li>American Geriatrics Society* </li></ul><ul><li>American Medical Association </li></ul><ul><li>* Denotes CSS membership </li></ul><ul><li>American Medical Directors Association </li></ul><ul><li>American Osteopathic Association </li></ul><ul><li>American Society of Clinical Oncology </li></ul><ul><li>American Society of Addiction Medicine </li></ul><ul><li>Association of Professors of Medicine </li></ul><ul><li>Association of Program Directors in Internal Medicine </li></ul><ul><li>Infectious Diseases Society of America* </li></ul><ul><li>Clerkship Directors in Internal Medicine </li></ul><ul><li>Society for Adolescent Medicine* </li></ul><ul><li>Society of Critical Care Medicine* </li></ul><ul><li>Society of General Internal Medicine* </li></ul>
    7. 7. Process to Define PCMH Using NCQA’s Physician Practice Connections <ul><li>AAFP, AAP, ACP and AOA reviewed PPC elements, documentation requirements and scoring methodology for voluntary recognition process </li></ul><ul><li>Using consensus-driven process identified standards for PCMH and the associated documentation </li></ul><ul><li>Developed scoring methodology that includes “must have” elements and </li></ul><ul><ul><li>Establishes the “first rung” of the ladder </li></ul></ul><ul><ul><ul><li>Practices meeting this standard evidences basic practice systems consistent with PCMH model. </li></ul></ul></ul><ul><ul><li>Identifies more sophisticated levels of the PCMH </li></ul></ul><ul><li>PCC-PCMH tool available January, 2008 </li></ul>
    8. 8. Sections (Points) PPC 1: Access & Communication (9) PPC 2: Patient Tracking & Registry Functions (21) PPC 3: Care Management (20) PPC 4: Patient Self-Management Support (6) PPC 5: Electronic Prescribing (8) PPC 6: Test Tracking (13) PPC 7: Referral Tracking (4) PPC 8: Performance Reporting & Improvement (15) PPC 9: Advanced Electronic Communication (4) TOTAL POINTS: 100
    9. 9. Physician Practice Connections – PCMH Levels Level 1: 25-49 Points; 5/10 Must Pass Level 2: 50-74 Points; 10/10 Must Pass Level 3: 75+ Points; 10/10 Must Pass Increasing prospective $
    10. 10. Model Clarifications <ul><li>PCMH model is NOT a gatekeeper model </li></ul><ul><ul><li>Pt can see any physician, specialist/subspecialist allowed by plan…..does not require approval by PCMH practice </li></ul></ul><ul><ul><li>Nature of the model encourages closer ties to PCMH to help meet pt’s medical needs/preferences and help pt navigate complex health care system . </li></ul></ul><ul><li>PCMH model is NOT specialty specific </li></ul><ul><ul><li>Model is most consistent with primary care practices </li></ul></ul><ul><ul><li>There are patient subgroups where specialty/subspecialty practice would be more appropriate PCMH. </li></ul></ul>
    11. 11. ACP and Others Recommend Supporting PCMH with Hybrid Payment Model <ul><li>Three-component payment model that consists of: </li></ul><ul><ul><li>Per patient, per month (PMPM) care coordination payment that accounts for </li></ul></ul><ul><ul><ul><li>The physician and non-physician clinical staff work required to manage care outside a face-to-face visit </li></ul></ul></ul><ul><ul><ul><li>The practice system redesign and technology acquisition </li></ul></ul></ul><ul><ul><ul><ul><li>Prospective </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Risk adjusted </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Laddered </li></ul></ul></ul></ul><ul><ul><li>Continued per visit fee-for-service (FFS) payment </li></ul></ul><ul><ul><li>Performance based component based on evidence-based quality measure reporting and patient satisfaction </li></ul></ul>
    12. 12. <ul><li>Patient-Centered Primary Care Collaborative </li></ul><ul><li>Articles in NEJM, Health Affairs, Annals of Internal Medicine, Trade & Lay Press </li></ul><ul><li>Legislation </li></ul><ul><li>Medicaid transformation </li></ul><ul><li>Multi-payer/multi-player commercial plans </li></ul>Expanding Interest in the PCMH
    13. 13. Patient Centered Primary Care Collaborative (PCPCC) <ul><li>Announced May 10, 2007 </li></ul><ul><li>Coalition of over 250 major employers, consumer groups, professional societies, and other stakeholders </li></ul><ul><li>Recognizes the PCMH and need for supporting a better compensation model </li></ul><ul><li>http://www.pcpcc.net </li></ul>
    14. 14. Endorsers of the PCPCC* <ul><li>AARP </li></ul><ul><li>AAFP </li></ul><ul><li>AAP </li></ul><ul><li>ACP </li></ul><ul><li>AHQA </li></ul><ul><li>Aetna </li></ul><ul><li>AOA </li></ul><ul><li>Aurum Dx </li></ul><ul><li>Blue Cross Blue Shield Association </li></ul><ul><li>Bridges to Excellence </li></ul><ul><li>The Center for Excellence in Primary Care </li></ul><ul><li>The Center for Health Value Innovation </li></ul><ul><li>Cigna </li></ul><ul><li>CVS Caremark </li></ul><ul><li>Disease Management Association of America </li></ul><ul><li>eHealth Initiative </li></ul><ul><li>The ERISA Industry Committee </li></ul><ul><li>Exelon Corp </li></ul><ul><li>Foundation for Informed Medical Decision Making </li></ul><ul><li>*Not all current members are included on this list. </li></ul><ul><li>General Motors </li></ul><ul><li>Health Dialogue </li></ul><ul><li>Humana </li></ul><ul><li>HR Policy Association </li></ul><ul><li>IBM </li></ul><ul><li>McKesson Corporation </li></ul><ul><li>NACHC </li></ul><ul><li>Nat’l Business Group on Health </li></ul><ul><li>Nat’l Business Coalition on Health </li></ul><ul><li>Nat’l Coalition on Health Care </li></ul><ul><li>NCQA </li></ul><ul><li>National Retail Foundation </li></ul><ul><li>Pacific Group on Health </li></ul><ul><li>Partners in Care </li></ul><ul><li>The Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins </li></ul><ul><li>Service Employers International Union </li></ul><ul><li>UnitedHealth </li></ul><ul><li>Walgreens Health Initiatives </li></ul><ul><li>Wellpoint </li></ul><ul><li>Wyeth </li></ul><ul><li>Xerox </li></ul>
    15. 15. PCPCC Summary of Demonstration Projects
    16. 17. Medicare Medical Home Demonstration (TRHCA 2006) <ul><li>Brief project description </li></ul><ul><ul><li>Focus on beneficiaries with multiple chronic conditions </li></ul></ul><ul><ul><li>Includes variety of practice settings in up to eight states to be announced by 12/08 — 50 practices per region. </li></ul></ul><ul><ul><li>2009 - practices selected and qualify for recognition status </li></ul></ul><ul><ul><li>2010 to 2012 – demon. project implemented </li></ul></ul><ul><li>Payment model </li></ul><ul><ul><li>Personal physician receives care management payment </li></ul></ul><ul><ul><li>Physician still receives FFS payments </li></ul></ul><ul><ul><li>Practices receive 80% of “reductions in expenditures (above 2%) ..that are attributable to the medical home” (minus care coordination fees paid) </li></ul></ul>
    17. 18. MMHD Care Management Fee <ul><li>HCC score indicates disease burden </li></ul><ul><li>Estimate that 25% of beneficiaries with HCC > or =1.6 and Medicare costs at least 60% higher than average </li></ul><ul><li>First 2% of savings not shared </li></ul><ul><li>80% of savings above 2% (minus fees) shared with practices </li></ul>Per Member per Month Payments HCC Score <1.6 HCC Score >1.6 Blended Rate Tier 1 $27.12 $80.25 $40.40 Tier 2 $35.48 $100.35 $51.70
    18. 19. State Medicaid Innovation <ul><li>As of Nov, 2008…31 states engaged in efforts to advance medical homes for Medicaid or SCHIP program participants </li></ul>Source: National Academy of State Health Policy (NASHP)
    19. 20. Map of Private Payer PCMH Demonstration Projects
    20. 21. Challenge: What Does it Co$t? <ul><li>Varying Assumptions… “apples to oranges” comparisons </li></ul><ul><ul><li>Future of Family Medicine 2004: Transition costs of $23,000 - $90,000 per physician* </li></ul></ul><ul><ul><ul><li>$15 PMPM for patients with chronic conditions </li></ul></ul></ul><ul><ul><li>Michael Bailit—review of PCMH estimates $3.00 - $9.00 pmpm** </li></ul></ul><ul><li>Deloitte Analysis*** </li></ul><ul><ul><li>Initial investment of $100,000/FTE </li></ul></ul><ul><ul><li>On-going expenses of $150,000/FTE </li></ul></ul>* http://www.annfammed.org/cgi/reprint/2/suppl_3/s1 ** [email_address] ***Deloitte: The Medical Home, Disruptive Innovation for a New Primary Care Model Accessed at: http://www.deloitte.com/dtt/cda/doc/content/us_chs_MedicalHome_w.pdf
    21. 22. Challenge: What Does it Co$t? <ul><li>Ambulatory ICU: $40-50 PMPM for primary care – but assumes more complex patients* </li></ul><ul><li>AMA RUC Evaluation for Medicare Medical Home Demonstration ** </li></ul><ul><ul><li>Tier 1 $25 pmpm Tier 2 $35 pmpm Tier 3 $50 pmpm </li></ul></ul><ul><li>ACP/Commonwealth “Costing the Medical Home Study” – Report Fall 2008 </li></ul><ul><ul><li>Assess the incremental cost of building the medical home based on NCQA PPC-PCMH framework </li></ul></ul><ul><li>* Mathematica—Medicare Medical Home design paper </li></ul><ul><li>** http://www.ama-assn.org/ama/pub/category/18531.html </li></ul>
    22. 23. Financing PCMH Services <ul><li>International & U.S. data demonstrate relationship between primary care and improved outcomes/reduced cost </li></ul><ul><li>Each 1% increase in primary care associated with decrease of 503 admissions, 2968 ED visits, 512 surgeries* </li></ul><ul><li>Medicare Beneficiaries assigned to Medical Homes—estimated saving $194 billion over 10 years.** </li></ul>*Kravet, S et al: Health Care Utilization and the Proportion of Primary Care Physicians. Amer J of Medicine, 2008; 121:142-148. ** Schoen et.al Bending the Curve. Commonwealth Fund 2007
    23. 24. Financing PCMH Services <ul><li>North Carolina Community Care Program </li></ul><ul><ul><li>Savings FY 2005 $ 77-85 million </li></ul></ul><ul><ul><li>Savings FY 2006 $ 154-170 million </li></ul></ul><ul><ul><li>http://www.pcpcc.net/content/north-carolina-community-care-press-release </li></ul></ul>
    24. 25. Financing PCMH Services <ul><li>Primary Sources of Savings </li></ul><ul><ul><li>Reduced unnecessary hospitalizations </li></ul></ul><ul><ul><li>Reduced hospital readmissions </li></ul></ul><ul><ul><li>Reduced unnecessary ER use </li></ul></ul><ul><ul><li>Decreased unnecessary specialty referrals </li></ul></ul><ul><ul><li>Increased efficiency in laboratory and diagnostic test expenditures </li></ul></ul><ul><ul><li>Increased efficiency in drug expenditures </li></ul></ul>
    25. 26. Update of CSS PCMH Activities <ul><li>Develop details regarding the relationship between the PCMH and subspecialty practices in the following areas: </li></ul><ul><ul><li>Referral issues, </li></ul></ul><ul><ul><li>Designation/transition issues, </li></ul></ul><ul><ul><li>Issues related to situations in which the subspecialty practice provides most of the care coordination </li></ul></ul><ul><ul><li>Information flow issues </li></ul></ul><ul><ul><li>responsibility issues. </li></ul></ul>
    26. 27. http:// www.acponline.org/running_practice/pcmh /