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Grand Rounds Jersey Shore Medical Center: Healthcare Reform, PCMH

Grand Rounds Jersey Shore Medical Center: Healthcare Reform, PCMH


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  • 1. Grand Rounds Jersey Shore Medical CenterRoad to Healthcare Reform, The Medical Home and ACOsAugust 30, 2011
    Steven R Peskin, MD, MBA, FACP
    EVP and Chief Medical Officer
    MediMedia USA
    Associate Clinical Professor of Medicine
    Robert Wood Johnson Medical School
  • 2. Road to Healthcare Reform
  • 3. Health reform: early 20th century
    1912: Theodore Roosevelt believed that no country could be strong whose people were sick and poor, campaigned on a platform that called for mandatory health insurance for workers
    AMA originally supported universal coverage, but by 1920, many physicians viewed compulsory insurance as threat to private practice, paternalistic, and “un-American” and AMA House of Delegates voted to oppose.
  • 4. Health reform: mid 20th century
    FDR spoke in favor of a right to medical care, but did not push compulsory HI over fear that it would endanger other Social Security reforms
    Bill after bill introduced to mandate coverage, but none passed the Congress
  • 5. Health reform: mid-20th century
    1945: Truman proposed a single plan to provide coverage for all age groups financed by 4% rise in Social Security payroll taxes
    AMA raised $3.5 million to oppose the bill, calling it “regimentation” and “totalitarianism”—even though Truman had no chance of getting it through a GOP-controlled Congress
  • 6. Health reform: the 1960s
    Kennedy campaigned for a comprehensive program of HI coverage for the elderly
    AMA established AMPAC with goal of electing conservatives to Congress and opposing Medicare
  • 7. Health reform: the 1960s
    Assassination of JFK and LBJ’s ascendancy changed everything; LBJ believed in Medicare even more than JFK and knew how to get legislation through Congress
    1964 elections: LBJ trounced Goldwater and the Democrats gained a 2-1 majority in Congress
  • 8. Health reform: the 1960s
    1965 Medicare and Medicaid passed, providing hospital and medical care for the elderly and creating a State/Federal partnership to cover the very poor
  • 9. Health reform: 1970s
    Under Nixon, Medicare expanded to cover disabled, Wage and Price controls; beginning of limits on Medicare payments to physicians and hospitals, increased regulation of physicians and health care facilities
    Nixon proposed mandatory employer-sponsored HI but didn’t pass Congress
  • 10. Health reform: 1970s
    • 1976: Carter campaigns for catastrophic plan, but after election priority shifts to controlling health care costs
    • 11. Sen. Kennedy offers new legislation for mandatory employer HI, government subsidies for poor, competition among private plans, and negotiated fees
    • 12. Bills fail due to economic recession, rising health costs, Congressional committee restructuring, and failure of advocates for comprehensive coverage to compromise
  • Health reform: 1980s
    Reagan favored repeal of many of the regulatory laws passed in the previous decade (e.g., National Health Planning Act and PSRO program); market-based “pro-competition” approach and tax credits favored for expanding HI
    Medicare catastrophic and prescription drug coverage enacted, but repealed as seniors objected to paying for it
    Growth in budget deficits led to new methods of paying doctors and hospitals
  • 13. Health reform: 1990s
    Rising health care costs and 46 million uninsured increased popular support for HI reform
    Clinton administration became the first since Truman to pursue a comprehensive plan to provide universal coverage
    Health Security Act called for mandated employer and individual coverage, managed competition, purchasing alliances, global budgets
    Plan failed to pass congressional committees
  • 14. Health reform: late-1990s
    Following defeat of Clinton plan, more modest goals were set for expanding coverage, including S-CHIP program for low-income children
    GOP take-over of Congress led to enactment of Balanced Budget Act of 1997, which mandated cuts in payments to hospitals, physicians, other providers and new “Medicare+Choice” program—first step toward goal of privatizing Medicare
  • 15. Health reform: early 21st century
    Ironically, Republican Congress passed and President George W. Bush sign into law the largest expansion of federal entitlements since 1965: Medicare Prescription Drug Program (Part D)
    Decision to run the program through private insurers and PBMs put a conservative “stamp” on expansion of entitlements
    No dedicated funding or offsets, adding to federal deficit
  • 16. Health reform: the present
    Obama campaigned for universal health care coverage, 2008 elections returned the Democrats to the White House and solidified control over Congress
    After 18 months of contentious debate, Congress passes health care reform in March, 2010
  • 17. Health reform: the present
    March 22, 2010:
    Almost 100 years after a U.S. President first proposed
    Health insurance for all, the Patient Protection and
    Affordable Care Act is signed into law
  • 18. ACA: Coverage
    No pre-existing condition exclusions
    Children (2010)
    Adults: Temporary high risk pool (2010), then all plans must cover (2014)
    No rescissions (2011)
    Up to age 26 covered by parents’ plan (2010)
    Preventive services with no-cost sharing (2010 for new plans, 2014 for all HI)
  • 19. ACA: Coverage
    Medicare Part D doughnut hole: $250 rebate (2010), 50% discount on brand name drugs (2011), to be completely phased out by 2020
    Individual and small business tax credits applied to purchase of HI through state exchanges (2014)
    Qualified health plans must offer basic benefits packages: bronze, silver, gold, platinum, plus low cost-plan for under age 30 (2014)
  • 20. ACA: Coverage
    Large employers must pay a penalty if their employees obtain coverage through an exchange (2014)
    Individuals required to buy coverage or pay penalty (2014)
    Medicaid expanded to 133% of FPL with 100% of cost initially paid for by federal government (2014), phases down to 90%
  • 21. ACA: Coverage
    When fully implemented, 34 million previously uninsured Americans will have coverage (94% of legal residents)
    Half by HI offered through exchanges, half by Medicaid
    But most Americans will continue to obtain coverage through employer-sponsored HI
  • 22. ACA: Workforce
    Primary Care Incentive Program: 10% bonus for designated services by primary care physicians (2011-2015)
    Medicaid primary care parity: states can pay no less than Medicare rates for visits and vaccines by primary care physicians (2013, 2014)
    Workforce Commission (appointed 2011, not yet funded) to project workforce needs and addresses barriers to primary care
  • 23. ACA: Workforce
    Unused residency slots redistributed to primary care (2011)
    GME offered through Teaching Health Centers (2011)
    NHSC: more slots for scholarships and loan forgiveness, higher maximum awards, and part-time awards (2011)
    Community Health Centers (2011)
  • 24. ACA: Workforce
    Title VII funding for primary care training programs, scholarships, faculty and curricula development (2011)
    State workforce grants (2011)
    State grants for primary care extension program (2011)
    Grants for health teams to support smaller practices become PCMHs (2011)
  • 25. ACA: Cost and Quality
    Center on Medicare and Medicaid Innovation (ongoing)
    ACOs
    Bundling
    Other voluntary pilots to align incentives with value
    Must include models to reform primary care payments
    Pay-for-performance (ongoing)
    Review of Mis-valued services (ongoing)
  • 26. ACA: Cost and Quality
    Insurers must spend at least 85% of premium dollar on direct patient care or pay a rebate (80% for small employers), 2011
    Insurers will be required to streamline and reduce paperwork on patients and physicians, including enrollment, electronic funds transfers, and authorization requirements or pay a fine (rules to be rolled out starting in 2011)
  • 27. ACA: Cost and Quality
    Patient-Centered Outcomes Research Institute (ongoing)
    Wellness and prevention trust fund (ongoing)
    National Quality Strategy (2011)
    Employers may offer 50% premium discount for employees who achieve personal health goals (2014)
  • 28. How is the ACA funded?
    Annual fee on health insurers and excise tax on high cost health plans
    Excise tax on medical devices and fee on drug manufacturers
    Tanning salon tax
    Tax on earned/unearned income of higher wage persons
    Pay cuts to hospitals, home health and MA plans
  • 29. Healthcare Reform and the Patient Centered Medical Home
  • 30. The Need
  • 31. Need for a New Healthcare Delivery Model
    Increasing costs
    Healthcare costs are growing faster than the economy and the cost of care is becoming difficult for employers, government and individuals to meet.
    Need to improve quality
    Patients receiving recommended treatment 55 % of the time
    Poor U.S. performance on healthcare benchmarks compared to other developed countries despite spending more.
    Regional variation
    Healthcare cost and quality vary substantially among geographic regions. Little relationship between cost and quality.
  • 32. Need for a New Healthcare Delivery Model
    Inadequate response to chronic care needs
    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
    Decreased Interest in Primary Care
    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.
    Both domestic and international data indicating that higher proportion of primary care physicians related to higher healthcare quality and lower costs.
  • 33. Key Elements of Patient Centered Medical Home
  • 34. A Joint Proposed SolutionThe Patient-Centered Medical Home (PCMH)
    • Modern “medical home” concept originally in Pediatric literature in the 1960’s—a central source of care for “Special Needs” children.
    • 35. AAFP—Future of Family Medicine Project (2004) “Personal Medical Home”
    • 36. ACP—Advanced Medical Home (2006)
    • 37. 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”.
    • 38. Nexus of patient-centered care, primary care and chronic care model concepts
  • The Patient-Centered Medical Home
    Redesigns clinical delivery and payment to facilitate
    Patient-centered, longitudinal, coordinated care delivered by a “recognized” practice with a personal physician
    Who accepts responsibility for the patient’s “whole person”
    Who acts in partnership with patients and in collaboration with multidisciplinary teams (nurses, physician specialists, health educators, pharmacists)
    Who uses practice level systems to improve access and communication, care integration, patient safety and outcomes
    Who accepts accountability for care provided through on-going performance measurement and quality improvement.
  • 39. A New Model of Care that Redesignsthe Way Primary Care is Delivered and Financed
    Patient
    Personal Physician
    • Trusted personal physician
    • 40. Physician who provides, manages and facilitates care
    • 41. Care is coordinated or integrated across healthcare system
    • 42. More accessible practice with increased hours and easier scheduling
    • 43. Enhanced payment that recognizes the added value of delivering care through the PCMH model
    • 44. Assistance to practices seeking transformation
    • 45. Support to practices adopting HIT for QI
  • Not Defined by any Certain Specialty
    v
    Personal Physician
    Patient
  • 46. Physician as Facilitator, Not a Gatekeeper
    Personal Physician
    Patient
    Pharmacist Care
    Specialist Care
    Hospital Care
  • 47. (5) Changes in Clinician Incentives
    Improved Patient Interaction
    Blended Payment
    Better Work Environment
    • More time for patients
    • 48. Better communication and access
    • 49. Case management
    Fee For Service
    • Fee for service
    • 50. Prospective payment
    • 51. Pay for outcomes
    • 52. Team effort
    • 53. Increased responsibility for admin and clinicians
    Personal Physician
  • 54. 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
    Nine Core Components
  • 55.
  • 56. Demonstration Projects
  • 57. (Patient Centered Medical Home)
    6% decrease in hospital admissions
    24 % decrease emergency room
    $500, Per member per years savings
  • 58. Horizon Blue Cross Blue Shield/Partners In Care
    For the New Jersey State Health Benefits Program
  • 59. Results: Clinical Process Metric Improvement
    HbA1c Testing
    HbA1c Testing
    January 2007
    November2007
    January 2007
    November2007
    Permission from Horizon Blue Cross Blue Shield and Partners in Care, Corp.
  • 60.
  • 61.
  • 62. Marillac’s Integrated Care Patients (PCMH)
  • 63. Overview of PCMH Commercial Pilot Activity
    • 22 projects
    • 64. 16 states
  • Overview of PCMH Commercial Pilot Activity (cont.)
    Additionally, new projects are under development in the previous states, such as Colorado (Family Medicine Residency Program), Michigan (Priority Health), and Tennessee (BCBS-TN)
  • 65. Initiatives to Advance Medical Homes in Medicaid/ SCHIP
    = Identified to have a medical home initiative
    Source: National Academy for State Health Policy State Scan, November 2008
  • 66. Combined Medical Home Activity
  • 67. Three models involve a retrospective bundled payment arrangement, and one model would pay providers prospectively
    Healthcare Reform: Accountable Care Organizations
  • 68. Accountable Care Organizations
    “…consist of providers who are jointly held accountable for achieving measured quality improvements and reductions in the rate of spending growth.” ¹
    MEDPAC Explanation: “…a group of physicians teamed with a hospital would have joint responsibility for the quality and cost of care provided to a large Medicare patient population…Potential ACOs include: integrated delivery systems, physician–hospital organizations, a hospital plus multispecialty groups, and a hospital teamed with independent practices.” ²
    ¹McClellan et al: Health Affairs, May 2010
    ²MEDPAC June 2009 report
  • 69. Integrated Delivery System
    Practice
    Team
    Physician
    Practice
    Team
    Practice
    Team
    Patient
    Physician
    Physician
    Physician
    Clinical Integration
    IndependentPractice Assoc.
    Practice
    Team
    Accountable Care Organization
  • 70. Provider Organizations That Can Become ACOs
  • 71. ACO Payment Options
  • 72. U.S. Encourages Bundling Medicare Payments
    The Centers for Medicare and Medicaid invited providers on Tuesday to help develop four models to bundle payments as part of a larger effort to improve patient care and reduce costs.
    The program is meant to encourage hospitals, doctors and other specialists to coordinate in treating a patient's specific condition during a single hospital stay and recovery.
    The four models give providers flexibility on how they get paid and for which services, as well as give them financial incentives to avoid unnecessary or duplicative procedures. Three models involve a retrospective bundled payment arrangement, and one model would pay providers prospectively
    Applicants for these models would also decide whether to define the episode of care as the acute care hospital stay only (Model 1), the acute care hospital stay plus post-acute care associated with the stay (Model 2), or just the post-acute care, beginning with the initiation of post-acute care services after discharge from an acute inpatient stay (Model 3).  Under the fourth model, CMS would make a single, prospective bundled payment that would encompass all services furnished during an inpatient stay by the hospital, physicians and other practitioners.
    Three models involve a retrospective bundled payment arrangement, and one model would pay providers prospectively
  • 73. 7 Core ACO Competencies and Associated Critical Success Factors
  • 74. 7 Core ACO Competencies and Associated Critical Success Factors
  • 75. Three models involve a retrospective bundled payment arrangement, and one model would pay providers prospectively
    Thank You!
    Discussion