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THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
THE PATIENT-CENTERED MEDICAL HOME (PC-MH)
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THE PATIENT-CENTERED MEDICAL HOME (PC-MH)

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  • Children: Irrespective of insurance status Rely on emergency rooms for their primary source of medical care Emergency rooms are not designed for primary care Appropriate follow-up care is lacking
  • SBIRT = screening, brief intervention and referral to treatment
  • Transcript

    • 1. THE PATIENT-CENTERED MEDICAL HOME (PC-MH) THE OKLAHOMA PERSPECTIVE STEVEN A. CRAWFORD, M.D. 2007 CHAIR, AAFP COMMISSION ON GOVERNMENTAL ADVOCACY PROFESSOR & CHAIR OU COLLEGE OF MEDICINE DEPARTMENT OF FAMILY & PREVENTIVE MEDICINE
    • 2. Hamster Health Care Joseph E. Scherger, MD, MPH; ICSI/IHI Colloquium, May 18, 2007
    • 3. Hamster Health Care <ul><li>“ Across the globe doctors are miserable because they feel like hamsters on a treadmill. They must run faster just to stand still …. </li></ul><ul><li>The result of the wheel going faster is not only a reduction in the quality of care but also a reduction in professional satisfaction and burnout among doctors.” </li></ul>Ian Morrison & Richard Smith. BMJ. 2000;321:1541-1542
    • 4. TOPICS <ul><li>WHAT IS A PC-MH? </li></ul><ul><li>WHY IN OKLAHOMA? </li></ul><ul><li>WHAT HAS BEEN DONE SO FAR? </li></ul><ul><li>WHAT IS IN THE FUTURE? </li></ul><ul><li>WHAT SHOULD BE DONE? </li></ul>
    • 5. What is a PC-MH? <ul><li>A PC-MH is a proposal to organize care based on the Institute of Medicine’s definition of patient-centered care: </li></ul><ul><li>“ providing care that is respectful of and responsive to individual patient preferences, needs, values and ensuring that patient values guide all clinical decisions” </li></ul>Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21 st century, March 2001; Presentation to the Patient-Centered Primary Care Collaborative: Call-to-Action Summit; Bob Doherty, SVP, Governmental Affairs and Public Policy American College of Physicians
    • 6. What is a PC-MH? <ul><li>CORE FEATURES OF A MEDICAL HOME </li></ul><ul><li>Personal Physician </li></ul><ul><li>Physician Directed Medical Practice </li></ul><ul><li>Whole Person Orientation </li></ul><ul><li>Care is Coordinated and/or Integrated </li></ul><ul><li>Quality and Safety </li></ul><ul><li>Enhanced Access </li></ul><ul><li>Payment Reform </li></ul>Joint Principles of the patient-centered medical home. www.medical-homeinfo.org/Joint%20Statement.pdf 10-24-07
    • 7. WHY IS IT IMPORTANT? <ul><li>In the U.S., PCP supply is consistently associated with improved health outcomes for conditions like cancer, heart disease, stroke, infant mortality, low birth weight, life expectancy, and self-rated care. </li></ul><ul><li>In England, each additional PCP per 10,000 persons is associated with a approximate 6% decrease in mortality. </li></ul><ul><li>In the U.K., an increase in PCP’s resulted in a significant decrease in both acute and chronic hospital admissions. </li></ul>Starfield B. Shi L, and Macinko J. Contributions of Primary Care to Health Systems and Health, Millbank Quarterly, Vol. 83, No. 3, 2005 (457-502)
    • 8. WHY IS IT IMPORTANT? <ul><li>U.S. adults who reported having a PCP rather than a specialist as their regular source of care had lower 5 year mortality rates after controlling for initial differences in health status, demographics, health insurance status, health perceptions, reported diagnosis, and smoking status. </li></ul>Starfield B. Shi L, and Macinko J. Contributions of Primary Care to Health Systems and Health, Millbank Quarterly, Vol. 83, No. 3, 2005 (457-502)
    • 9. WHY IS IT IMPORTANT? <ul><li>In the U.S., when adults have a medical home, access to needed care, receipt of routine preventive screenings, and management of chronic conditions improve substantially. </li></ul>A. C. Beal, M. M. Doty, S. E. Hernandez, K. K. Shea, and K. Davis, Closing the Divide: How Medical Homes Promote Equity in Health Care: Results From The Commonwealth Fund 2006 Health Care Quality Survey , The Commonwealth Fund, June 2007
    • 10. WHO CARES? <ul><li>Consumers </li></ul><ul><li>Business Community </li></ul><ul><li>Provider Community </li></ul><ul><li>Payors </li></ul><ul><li>Advocacy Groups </li></ul>
    • 11. WHO CARES? <ul><li>Endorsed by… </li></ul><ul><ul><li>The AAP, AAFP, ACP, and AOA, representing approximately 333,000 physicians </li></ul></ul><ul><ul><li>The Patient-Centered Primary Care Collaborative, representing employers, physicians, consumers and health plans </li></ul></ul>
    • 12. WHY IN OKLAHOMA? <ul><li>2007 Summit Recommendation #9 </li></ul><ul><ul><li>Promote Patient-Centered Medical Homes </li></ul></ul><ul><li>50th rank in health status improvement since 1990 </li></ul><ul><li>43rd in PCP’s per 100,000 population </li></ul><ul><ul><li>Oklahoma: 73 per 100,000 </li></ul></ul><ul><ul><li>National median: 88 per 100,000 </li></ul></ul><ul><li>Three of every five Oklahoma children (58.5 percent) do not have a medical home </li></ul>
    • 13. What’s Been Done So Far? <ul><li>November 2007: CSG Joint Resolution </li></ul><ul><ul><li>Endorses All State Legislatures to Promote the PCMH </li></ul></ul><ul><li>March 2008: OK HCR 1058 </li></ul><ul><ul><li>Endorses PC-MH Principles </li></ul></ul><ul><li>May 2008: OK SB 1863 </li></ul><ul><ul><li>Encourages Legislative Study of the PC-MH </li></ul></ul><ul><li>May 2008: SB 1656 </li></ul><ul><ul><li>PC-MH Task Force Formation </li></ul></ul><ul><li>November 2008: OHCA Medical Home Initiative </li></ul>
    • 14. What is SoonerCare Choice Today? <ul><li>SoonerCare Choice is a managed care model in which each member is linked to a PCP who serves as their “medical home” </li></ul><ul><li>PCP’s manage the basic health care needs, including after hours care and specialty referral of the members on their panel </li></ul>07/22/10 OCHA MEDICAL HOME INITIATIVE
    • 15. OHCA PCP Network <ul><li>SoonerCare Choice has over 400,000 members enrolled statewide </li></ul><ul><li>Over 1,000 PCP’s (up from 800+ in 2003) </li></ul><ul><li>Each PCP has a max panel of 2,500 </li></ul><ul><li>PA or APN PCP’s have a max panel of 1,250 </li></ul><ul><li>Average panel size - 300 members per PCP </li></ul>07/22/10 OCHA MEDICAL HOME INITIATIVE
    • 16. Who Can be a PCP Today? <ul><ul><li>Clinicians </li></ul></ul><ul><ul><ul><li>General Practitioners </li></ul></ul></ul><ul><ul><ul><li>Family Physicians </li></ul></ul></ul><ul><ul><ul><li>Internal Medicine </li></ul></ul></ul><ul><ul><ul><li>OB/GYNs </li></ul></ul></ul><ul><ul><ul><li>Pediatricians </li></ul></ul></ul><ul><ul><ul><li>Physician Assistants (PA) </li></ul></ul></ul><ul><ul><ul><li>Advance Practice Nurses (APN) </li></ul></ul></ul>07/22/10 <ul><ul><li>Entity’s </li></ul></ul><ul><ul><li>FQHC’s </li></ul></ul><ul><ul><li>RHC’s </li></ul></ul><ul><ul><li>IHS Facilities </li></ul></ul>OCHA MEDICAL HOME INITIATIVE
    • 17. Medical Advisory Task Force (MAT) <ul><li>MAT was created February 2007 at “request of the providers” </li></ul><ul><li>Representatives from respective provider associations </li></ul><ul><ul><li>OOA </li></ul></ul><ul><ul><li>OSMA </li></ul></ul><ul><ul><li>OAFP </li></ul></ul><ul><ul><li>AAP, Oklahoma Chapter </li></ul></ul>07/22/10 OCHA MEDICAL HOME INITIATIVE
    • 18. Medical Advisory Taskforce Four Top Priorities <ul><li>Change in current payment structure </li></ul><ul><li>Medical home </li></ul><ul><li>Eliminate auto-assignment </li></ul><ul><li>Credentialing </li></ul>07/22/10 OCHA MEDICAL HOME INITIATIVE
    • 19. Current SoonerCare Choice Payment <ul><li>Monthly capitated payment “bundles”: </li></ul><ul><li>Case Management / Care Coordination Fee </li></ul><ul><li>Primary care office visits </li></ul><ul><li>Limited lab services </li></ul><ul><li>Other care paid on FFS basis </li></ul><ul><li>Incentive Payments </li></ul><ul><li>EPSDT / 4 th DTaP bonus </li></ul>07/22/10 OCHA MEDICAL HOME INITIATIVE
    • 20. Recommended PCMH Payment <ul><li>A monthly care coordination payment </li></ul><ul><li>A visit-based fee-for-service component </li></ul><ul><li>A performance-based component </li></ul><ul><ul><li>Source: The Patient Centered Primary Care Collaborative http://www.patientcenteredprimarycare.org/ </li></ul></ul>07/22/10 The most effective way to re-align payment incentives to support the PCMH would be to combine traditional fee-for-service for office visits with a three part model that includes: OCHA MEDICAL HOME INITIATIVE
    • 21. SoonerCare Choice Comparison 07/22/10 <ul><li>Prepayment for case management only </li></ul><ul><li>Referrals only needed for specialty care </li></ul><ul><li>Group contracts must designate a medical director </li></ul><ul><li>Elimination of default auto-assignment </li></ul><ul><li>Online provider enrollment </li></ul><ul><li>Current funding remains the same </li></ul><ul><li>Provider determines medical necessity </li></ul><ul><li>Federal restrictions (e.g. EMTALA, co-pays) </li></ul>What Stays the Same? What Changes? OCHA MEDICAL HOME INITIATIVE
    • 22. Additional SoonerCare Choice Changes <ul><li>Coverage of new codes (e.g. after hours) </li></ul><ul><li>OB/GYN that do not provide primary care may no longer be PCP’s </li></ul><ul><li>Members may change PCP’s within the month </li></ul><ul><li>Case mgmt payment will be based on date processed </li></ul>07/22/10 OCHA MEDICAL HOME INITIATIVE
    • 23. SoonerCare Choice Demographics 07/22/10 84% are Children OCHA MEDICAL HOME INITIATIVE
    • 24. SoonerCare Choice Demographics, Cont’d 07/22/10 Estimated Percentage of Adults with Chronic Conditions and Children with Special Health Care Needs OCHA MEDICAL HOME INITIATIVE
    • 25. Current PC Payment Structure <ul><li>Capitated bundled rates include payment for : </li></ul><ul><li>Monthly case management based on age/sex cells </li></ul><ul><ul><li>Weighted average = $2.23 pmpm </li></ul></ul><ul><li>E&M Visits based on % of Medicare fee schedule and actuarial based utilization assumptions (somewhat higher than actual encounter data received) </li></ul>07/22/10 Average total payment for physicians = $30 pmpm OCHA MEDICAL HOME INITIATIVE
    • 26. Proposed New SoonerCare Choice Payments <ul><li>Monthly Case Mgt - Care Coordination Fee </li></ul><ul><ul><li>Peer grouped by type of panel and capabilities of practice </li></ul></ul><ul><li>Visit based component </li></ul><ul><ul><li>Fee for service </li></ul></ul><ul><li>Expanded Performance Component (SoonerExcell) </li></ul><ul><li>Transitional Payments in Year 1 </li></ul>07/22/10 “ Unbundled” to incorporate PCMH principles OCHA MEDICAL HOME INITIATIVE
    • 27. Medicare Medical Home Demonstration eff. 1/1/09 <ul><li>Tier 1 Entry Level $31.18 </li></ul><ul><li>Tier 2 Typical $39.39 </li></ul><ul><li>Tier 3 Advanced $45.96 </li></ul><ul><li>Estimated care management fee based on RVS Update Committee (RUC) RVU recommendations for practices that qualify as medical homes. Includes increased cost for 1 nurse care manager </li></ul>07/22/10 OCHA MEDICAL HOME INITIATIVE
    • 28. Chronic conditions and the Medicare population 07/22/10 <ul><li>Currently, 78% of the Medicare population suffer from one or more chronic conditions that require ongoing medical management </li></ul><ul><ul><li>Gottlich. Partnership for Solutions, Medical Necessity Determination in the Medicare Program (January 2003) </li></ul></ul>OCHA MEDICAL HOME INITIATIVE
    • 29. <ul><ul><li>Panel Type </li></ul></ul><ul><ul><li>Children only </li></ul></ul><ul><ul><li>Adults and Children </li></ul></ul><ul><ul><li>Adults Only </li></ul></ul><ul><li>AND </li></ul><ul><ul><li>Medical Home Level </li></ul></ul><ul><ul><li>Tier 1 = Entry Level PCMH </li></ul></ul><ul><ul><li>Tier 2 = Standard PCMH </li></ul></ul><ul><ul><li>Tier 3 = Advanced PCMH </li></ul></ul>Case Management Fee 07/22/10 OCHA MEDICAL HOME INITIATIVE
    • 30. Care Coordination Fees for SoonerCare Choice <ul><li>Rates based on a blend of the: </li></ul><ul><ul><li>RUC recommendation for the Medicare chronic condition population </li></ul></ul><ul><ul><li>Payment for generally healthy Medicaid population </li></ul></ul>07/22/10 OCHA MEDICAL HOME INITIATIVE
    • 31. Tier 1 Requirements 07/22/10 <ul><li>Provides or coordinates all medically necessary primary/preventive services </li></ul><ul><li>Participates in VFC & OSIIS if serving children </li></ul><ul><li>Uses patient-specific charting system </li></ul><ul><li>Uses medication reconciliation system </li></ul><ul><li>Uses lab tracking & patient notification system </li></ul>OCHA MEDICAL HOME INITIATIVE
    • 32. Tier 1 Requirements 07/22/10 <ul><li>Utilizes referral tracking system </li></ul><ul><li>Provides care coordination & continuity of care </li></ul><ul><li>Supports family participation in care coordination </li></ul><ul><li>Provides adm capability to obtain specialty referrals </li></ul><ul><li>Provides adm capability to obtain prior auth’s </li></ul><ul><li>Provides patient education and support </li></ul>OCHA MEDICAL HOME INITIATIVE
    • 33. Tier 1 Optional Add-Ons Must do both 07/22/10 <ul><li>Accepts electronic communication from OHCA </li></ul><ul><li>Provides 24/7 voice to voice telephone coverage with immediate availability of an on-call medical professional </li></ul>OCHA MEDICAL HOME INITIATIVE
    • 34. Tier 1 Care Mgt Payments (pmpm) <ul><li>Type of Panel </li></ul><ul><li>Children Only = $3.58 </li></ul><ul><li>Children and Adults = $4.33 </li></ul><ul><li>Adults Only = $5.02 </li></ul><ul><li>Add-on payment = $0.55 </li></ul>07/22/10 OCHA MEDICAL HOME INITIATIVE
    • 35. Tier 2 Requirements 07/22/10 <ul><li>Obtains provider & patient MH role mutual agreement </li></ul><ul><li>Maintains a full-time practice (30 hrs appt/wk) </li></ul><ul><li>Uses scheduling processes that promote PCP continuity </li></ul><ul><li>Uses mental health & substance abuse screening & referral procedures </li></ul>OCHA MEDICAL HOME INITIATIVE
    • 36. Tier 2 Requirements 07/22/10 <ul><li>Uses OHCA data to identify & track MH patients both inside and outside of the PCP practice </li></ul><ul><li>Coordinates care & follow-up for MH patients from inpatient & outpatient facilities, as well as patient care outside of the PCP’s office </li></ul><ul><li>Implements processes to promote access & communication </li></ul>OCHA MEDICAL HOME INITIATIVE
    • 37. Tier 2 Add-On Options Must Choose 3 07/22/10 <ul><li>Develops a PCP-led practice team </li></ul><ul><li>Provides after-visit follow up for the MH patient </li></ul><ul><li>Adopts EB clinical guidelines on preventive & chronic care </li></ul><ul><li>Uses medication reconciliation to avoid interactions or duplications </li></ul>OCHA MEDICAL HOME INITIATIVE
    • 38. 07/22/10 <ul><li>Provides care to voluntarily enrolled children who are in state custody </li></ul><ul><li>Uses SBIRT procedures to assess an individual’s behavioral health status </li></ul><ul><li>Participates in practice facilitation program </li></ul><ul><li>Provides 4 hours of after-hours care outside of 8am to 5pm, Monday - Friday </li></ul>OCHA MEDICAL HOME INITIATIVE Tier 2 Add-On Options Must Choose 3
    • 39. Tier 2 Care Mgt Payments (pmpm) <ul><li>Type of Panel </li></ul><ul><li>Children Only = $4.65 </li></ul><ul><li>Children and Adults = $5.64 </li></ul><ul><li>Adults Only = $6.53 </li></ul><ul><li>Add-on payment = $0.55 </li></ul>07/22/10 OCHA MEDICAL HOME INITIATIVE
    • 40. Tier 3 Requirements 07/22/10 <ul><li>Organizes & trains staff in roles for care management </li></ul><ul><li>Creates & maintains a prepared & proactive care team </li></ul><ul><li>Provides timely call back to patients </li></ul><ul><li>Adheres to EB clinical practice guidelines on preventive & chronic care </li></ul><ul><li>Uses health assessment to characterize patient needs & risks </li></ul><ul><li>Documents patient self-mgt plan for those with chronic disease </li></ul><ul><li>Develops a PCP-led health care team </li></ul><ul><li>Provides after-visit follow up for the MH patient </li></ul>OCHA MEDICAL HOME INITIATIVE
    • 41. Tier 3 Requirements 07/22/10 <ul><li>Adopts specific EB guidelines </li></ul><ul><li>Uses medication reconciliation to avoid interactions or duplications </li></ul><ul><li>Provides care to voluntarily enrolled children who are in state custody </li></ul><ul><li>Uses SBIRT procedures to assess an individual’s behavioral health status </li></ul><ul><li>Provides 4 hours of after-hours care outside of 8am to 5pm, Monday – Friday </li></ul><ul><li>Participates in practice facilitation program </li></ul>OCHA MEDICAL HOME INITIATIVE
    • 42. Tier 3 Add-On Options Must do all 3 07/22/10 <ul><li>Provides secure patient access system to personal health information </li></ul><ul><li>Uses integrated care plan to plan & guide patient care </li></ul><ul><li>Reports PCP performance to OHCA </li></ul>OCHA MEDICAL HOME INITIATIVE
    • 43. Tier 3 Care Mgt Rates (pmpm) <ul><li>Type of Panel </li></ul><ul><li>Children Only = $6.19 </li></ul><ul><li>Children and Adults = $7.50 </li></ul><ul><li>Adults Only = $8.69 </li></ul><ul><li>Add-On Payment = $0.55 </li></ul>07/22/10 OCHA MEDICAL HOME INITIATIVE
    • 44. SoonerExcell Components <ul><li>Child health exams (EPSDT) and 4 th DTaP = $ 1.5 m </li></ul><ul><li>Generic drug prescribing = $ 0.5 m </li></ul><ul><li>Cervical cancer screenings = $ 0.3 m </li></ul><ul><li>Breast cancer screenings = $ 0.05 m </li></ul><ul><li>Physician inpatient admitting and visits = $ 0.85 m </li></ul><ul><li>ER utilization = $ 0.5 m </li></ul>07/22/10 OCHA MEDICAL HOME INITIATIVE
    • 45. THE MASSACHUSETTS LESSON
    • 46. <ul><ul><li>Engage PCMH Task Force to study the OHCA initiated Medical Home proposal in addition to it’s legislative mandate </li></ul></ul><ul><ul><li>Implement the OHCA Medical Home proposal </li></ul></ul><ul><ul><li>Explore using PCMH principles as a minimum standard for state-licensed commercial health insurance products </li></ul></ul><ul><ul><li>Strengthen the PCP workforce in the state </li></ul></ul><ul><ul><li>Promote education about and implementation of of the Medical Home principles by the: </li></ul></ul><ul><ul><ul><li>Health dept – General population </li></ul></ul></ul><ul><ul><ul><li>OID – Insurance companies </li></ul></ul></ul><ul><ul><ul><li>Provider associations (OSMA, OOA, OAFP, etc) </li></ul></ul></ul><ul><ul><ul><li>OHCA – SoonerCare members </li></ul></ul></ul><ul><ul><ul><li>OSEEGIB – their members </li></ul></ul></ul><ul><ul><ul><li>Insurance companies – their members </li></ul></ul></ul>POTENTIAL RECOMMENDATIONS

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