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

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

  • 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
  • Hamster Health Care Joseph E. Scherger, MD, MPH; ICSI/IHI Colloquium, May 18, 2007
  • Hamster Health Care
    • “ Across the globe doctors are miserable because they feel like hamsters on a treadmill. They must run faster just to stand still ….
    • 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.”
    Ian Morrison & Richard Smith. BMJ. 2000;321:1541-1542
  • TOPICS
    • WHAT IS A PC-MH?
    • WHY IN OKLAHOMA?
    • WHAT HAS BEEN DONE SO FAR?
    • WHAT IS IN THE FUTURE?
    • WHAT SHOULD BE DONE?
  • What is a PC-MH?
    • A PC-MH is a proposal to organize care based on the Institute of Medicine’s definition of patient-centered care:
    • “ providing care that is respectful of and responsive to individual patient preferences, needs, values and ensuring that patient values guide all clinical decisions”
    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
  • What is a PC-MH?
    • CORE FEATURES OF A MEDICAL HOME
    • Personal Physician
    • Physician Directed Medical Practice
    • Whole Person Orientation
    • Care is Coordinated and/or Integrated
    • Quality and Safety
    • Enhanced Access
    • Payment Reform
    Joint Principles of the patient-centered medical home. www.medical-homeinfo.org/Joint%20Statement.pdf 10-24-07
  • WHY IS IT IMPORTANT?
    • 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.
    • In England, each additional PCP per 10,000 persons is associated with a approximate 6% decrease in mortality.
    • In the U.K., an increase in PCP’s resulted in a significant decrease in both acute and chronic hospital admissions.
    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)
  • WHY IS IT IMPORTANT?
    • 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.
    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)
  • WHY IS IT IMPORTANT?
    • 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.
    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
  • WHO CARES?
    • Consumers
    • Business Community
    • Provider Community
    • Payors
    • Advocacy Groups
  • WHO CARES?
    • Endorsed by…
      • The AAP, AAFP, ACP, and AOA, representing approximately 333,000 physicians
      • The Patient-Centered Primary Care Collaborative, representing employers, physicians, consumers and health plans
  • WHY IN OKLAHOMA?
    • 2007 Summit Recommendation #9
      • Promote Patient-Centered Medical Homes
    • 50th rank in health status improvement since 1990
    • 43rd in PCP’s per 100,000 population
      • Oklahoma: 73 per 100,000
      • National median: 88 per 100,000
    • Three of every five Oklahoma children (58.5 percent) do not have a medical home
  • What’s Been Done So Far?
    • November 2007: CSG Joint Resolution
      • Endorses All State Legislatures to Promote the PCMH
    • March 2008: OK HCR 1058
      • Endorses PC-MH Principles
    • May 2008: OK SB 1863
      • Encourages Legislative Study of the PC-MH
    • May 2008: SB 1656
      • PC-MH Task Force Formation
    • November 2008: OHCA Medical Home Initiative
  • What is SoonerCare Choice Today?
    • SoonerCare Choice is a managed care model in which each member is linked to a PCP who serves as their “medical home”
    • PCP’s manage the basic health care needs, including after hours care and specialty referral of the members on their panel
    07/22/10 OCHA MEDICAL HOME INITIATIVE
  • OHCA PCP Network
    • SoonerCare Choice has over 400,000 members enrolled statewide
    • Over 1,000 PCP’s (up from 800+ in 2003)
    • Each PCP has a max panel of 2,500
    • PA or APN PCP’s have a max panel of 1,250
    • Average panel size - 300 members per PCP
    07/22/10 OCHA MEDICAL HOME INITIATIVE
  • Who Can be a PCP Today?
      • Clinicians
        • General Practitioners
        • Family Physicians
        • Internal Medicine
        • OB/GYNs
        • Pediatricians
        • Physician Assistants (PA)
        • Advance Practice Nurses (APN)
    07/22/10
      • Entity’s
      • FQHC’s
      • RHC’s
      • IHS Facilities
    OCHA MEDICAL HOME INITIATIVE
  • Medical Advisory Task Force (MAT)
    • MAT was created February 2007 at “request of the providers”
    • Representatives from respective provider associations
      • OOA
      • OSMA
      • OAFP
      • AAP, Oklahoma Chapter
    07/22/10 OCHA MEDICAL HOME INITIATIVE
  • Medical Advisory Taskforce Four Top Priorities
    • Change in current payment structure
    • Medical home
    • Eliminate auto-assignment
    • Credentialing
    07/22/10 OCHA MEDICAL HOME INITIATIVE
  • Current SoonerCare Choice Payment
    • Monthly capitated payment “bundles”:
    • Case Management / Care Coordination Fee
    • Primary care office visits
    • Limited lab services
    • Other care paid on FFS basis
    • Incentive Payments
    • EPSDT / 4 th DTaP bonus
    07/22/10 OCHA MEDICAL HOME INITIATIVE
  • Recommended PCMH Payment
    • A monthly care coordination payment
    • A visit-based fee-for-service component
    • A performance-based component
      • Source: The Patient Centered Primary Care Collaborative http://www.patientcenteredprimarycare.org/
    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
  • SoonerCare Choice Comparison 07/22/10
    • Prepayment for case management only
    • Referrals only needed for specialty care
    • Group contracts must designate a medical director
    • Elimination of default auto-assignment
    • Online provider enrollment
    • Current funding remains the same
    • Provider determines medical necessity
    • Federal restrictions (e.g. EMTALA, co-pays)
    What Stays the Same? What Changes? OCHA MEDICAL HOME INITIATIVE
  • Additional SoonerCare Choice Changes
    • Coverage of new codes (e.g. after hours)
    • OB/GYN that do not provide primary care may no longer be PCP’s
    • Members may change PCP’s within the month
    • Case mgmt payment will be based on date processed
    07/22/10 OCHA MEDICAL HOME INITIATIVE
  • SoonerCare Choice Demographics 07/22/10 84% are Children OCHA MEDICAL HOME INITIATIVE
  • 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
  • Current PC Payment Structure
    • Capitated bundled rates include payment for :
    • Monthly case management based on age/sex cells
      • Weighted average = $2.23 pmpm
    • E&M Visits based on % of Medicare fee schedule and actuarial based utilization assumptions (somewhat higher than actual encounter data received)
    07/22/10 Average total payment for physicians = $30 pmpm OCHA MEDICAL HOME INITIATIVE
  • Proposed New SoonerCare Choice Payments
    • Monthly Case Mgt - Care Coordination Fee
      • Peer grouped by type of panel and capabilities of practice
    • Visit based component
      • Fee for service
    • Expanded Performance Component (SoonerExcell)
    • Transitional Payments in Year 1
    07/22/10 “ Unbundled” to incorporate PCMH principles OCHA MEDICAL HOME INITIATIVE
  • Medicare Medical Home Demonstration eff. 1/1/09
    • Tier 1 Entry Level $31.18
    • Tier 2 Typical $39.39
    • Tier 3 Advanced $45.96
    • 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
    07/22/10 OCHA MEDICAL HOME INITIATIVE
  • Chronic conditions and the Medicare population 07/22/10
    • Currently, 78% of the Medicare population suffer from one or more chronic conditions that require ongoing medical management
      • Gottlich. Partnership for Solutions, Medical Necessity Determination in the Medicare Program (January 2003)
    OCHA MEDICAL HOME INITIATIVE
      • Panel Type
      • Children only
      • Adults and Children
      • Adults Only
    • AND
      • Medical Home Level
      • Tier 1 = Entry Level PCMH
      • Tier 2 = Standard PCMH
      • Tier 3 = Advanced PCMH
    Case Management Fee 07/22/10 OCHA MEDICAL HOME INITIATIVE
  • Care Coordination Fees for SoonerCare Choice
    • Rates based on a blend of the:
      • RUC recommendation for the Medicare chronic condition population
      • Payment for generally healthy Medicaid population
    07/22/10 OCHA MEDICAL HOME INITIATIVE
  • Tier 1 Requirements 07/22/10
    • Provides or coordinates all medically necessary primary/preventive services
    • Participates in VFC & OSIIS if serving children
    • Uses patient-specific charting system
    • Uses medication reconciliation system
    • Uses lab tracking & patient notification system
    OCHA MEDICAL HOME INITIATIVE
  • Tier 1 Requirements 07/22/10
    • Utilizes referral tracking system
    • Provides care coordination & continuity of care
    • Supports family participation in care coordination
    • Provides adm capability to obtain specialty referrals
    • Provides adm capability to obtain prior auth’s
    • Provides patient education and support
    OCHA MEDICAL HOME INITIATIVE
  • Tier 1 Optional Add-Ons Must do both 07/22/10
    • Accepts electronic communication from OHCA
    • Provides 24/7 voice to voice telephone coverage with immediate availability of an on-call medical professional
    OCHA MEDICAL HOME INITIATIVE
  • Tier 1 Care Mgt Payments (pmpm)
    • Type of Panel
    • Children Only = $3.58
    • Children and Adults = $4.33
    • Adults Only = $5.02
    • Add-on payment = $0.55
    07/22/10 OCHA MEDICAL HOME INITIATIVE
  • Tier 2 Requirements 07/22/10
    • Obtains provider & patient MH role mutual agreement
    • Maintains a full-time practice (30 hrs appt/wk)
    • Uses scheduling processes that promote PCP continuity
    • Uses mental health & substance abuse screening & referral procedures
    OCHA MEDICAL HOME INITIATIVE
  • Tier 2 Requirements 07/22/10
    • Uses OHCA data to identify & track MH patients both inside and outside of the PCP practice
    • Coordinates care & follow-up for MH patients from inpatient & outpatient facilities, as well as patient care outside of the PCP’s office
    • Implements processes to promote access & communication
    OCHA MEDICAL HOME INITIATIVE
  • Tier 2 Add-On Options Must Choose 3 07/22/10
    • Develops a PCP-led practice team
    • Provides after-visit follow up for the MH patient
    • Adopts EB clinical guidelines on preventive & chronic care
    • Uses medication reconciliation to avoid interactions or duplications
    OCHA MEDICAL HOME INITIATIVE
  • 07/22/10
    • Provides care to voluntarily enrolled children who are in state custody
    • Uses SBIRT procedures to assess an individual’s behavioral health status
    • Participates in practice facilitation program
    • Provides 4 hours of after-hours care outside of 8am to 5pm, Monday - Friday
    OCHA MEDICAL HOME INITIATIVE Tier 2 Add-On Options Must Choose 3
  • Tier 2 Care Mgt Payments (pmpm)
    • Type of Panel
    • Children Only = $4.65
    • Children and Adults = $5.64
    • Adults Only = $6.53
    • Add-on payment = $0.55
    07/22/10 OCHA MEDICAL HOME INITIATIVE
  • Tier 3 Requirements 07/22/10
    • Organizes & trains staff in roles for care management
    • Creates & maintains a prepared & proactive care team
    • Provides timely call back to patients
    • Adheres to EB clinical practice guidelines on preventive & chronic care
    • Uses health assessment to characterize patient needs & risks
    • Documents patient self-mgt plan for those with chronic disease
    • Develops a PCP-led health care team
    • Provides after-visit follow up for the MH patient
    OCHA MEDICAL HOME INITIATIVE
  • Tier 3 Requirements 07/22/10
    • Adopts specific EB guidelines
    • Uses medication reconciliation to avoid interactions or duplications
    • Provides care to voluntarily enrolled children who are in state custody
    • Uses SBIRT procedures to assess an individual’s behavioral health status
    • Provides 4 hours of after-hours care outside of 8am to 5pm, Monday – Friday
    • Participates in practice facilitation program
    OCHA MEDICAL HOME INITIATIVE
  • Tier 3 Add-On Options Must do all 3 07/22/10
    • Provides secure patient access system to personal health information
    • Uses integrated care plan to plan & guide patient care
    • Reports PCP performance to OHCA
    OCHA MEDICAL HOME INITIATIVE
  • Tier 3 Care Mgt Rates (pmpm)
    • Type of Panel
    • Children Only = $6.19
    • Children and Adults = $7.50
    • Adults Only = $8.69
    • Add-On Payment = $0.55
    07/22/10 OCHA MEDICAL HOME INITIATIVE
  • SoonerExcell Components
    • Child health exams (EPSDT) and 4 th DTaP = $ 1.5 m
    • Generic drug prescribing = $ 0.5 m
    • Cervical cancer screenings = $ 0.3 m
    • Breast cancer screenings = $ 0.05 m
    • Physician inpatient admitting and visits = $ 0.85 m
    • ER utilization = $ 0.5 m
    07/22/10 OCHA MEDICAL HOME INITIATIVE
  • THE MASSACHUSETTS LESSON
      • Engage PCMH Task Force to study the OHCA initiated Medical Home proposal in addition to it’s legislative mandate
      • Implement the OHCA Medical Home proposal
      • Explore using PCMH principles as a minimum standard for state-licensed commercial health insurance products
      • Strengthen the PCP workforce in the state
      • Promote education about and implementation of of the Medical Home principles by the:
        • Health dept – General population
        • OID – Insurance companies
        • Provider associations (OSMA, OOA, OAFP, etc)
        • OHCA – SoonerCare members
        • OSEEGIB – their members
        • Insurance companies – their members
    POTENTIAL RECOMMENDATIONS