1. Also in this Issue
p3 Defining Medical Home Status
Learn about a new set of criteria to recognize physician practices as medical homes.
p4 One Way to Increase DM Participation
Find out how disability integration made a difference in one company’s participation rate.
p5 What differentiates Matria’s
Get the scoop on an exciting new development.
Health & ProductivityThe latest health & productivity news brought to you by Matria SPRING 2008
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Hope for U.S.
The advanced medical home
model of care could improve the
way primary and principal care
are delivered and financed.
Find out how this model of care works
and how it supports and benefits health
enhancement, in an article by Michael
S. Barr, M.D., M.B.A., FACP, and Jack
Ginsburg, both of the American College of
Physicians. (page 2)
2. Advanced Medical Home
Model of Care Offers Hope for Ailing Healthcare System
By Michael S. Barr, M.D., M.B.A., FACP
and Jack Ginsburg, M.P.E.
he U.S. healthcare system is poorly prepared to meet
the current, let alone the future, healthcare needs of
an aging population. Healthcare costs are continuing
to grow faster than the economy, and employers,
government agencies and individuals are straining under
the financial burden.
In this environment, physicians are pressured to see
more patients in less time1
as they are inundated with
administrative paperwork and regulatory requirements. In
addition, they have the added pressure of staying current
with an overload of information in a medical environment
that is increasingly more technical and complicated, and they
struggle to keep their practices afloat in the face of declining
revenues and increasing costs.
Trusting, intimate relationships with patients have suffered
as physicians and patients struggle with the financial and
bureaucratic complexities of public and private insurance
coverage issues, which can cause substantial stress within
Physicians also must stay current with ever-expanding
medical knowledge and technology in accord with evolving
medical standards of quality. To make matters worse,
insufficient numbers of young physicians are entering
careers in primary care, and increasing numbers of older
physicians are dissatisfied with their careers and indicate
that they will soon discontinue practice.
In too many instances, unnecessary or inappropriate
healthcare services are provided because there is little
coordination of patient care among providers or across sites
As a solution, the American College of Physicians (ACP)
proposed the advanced medical home model which offers
the potential to improve U.S. healthcare by focusing
on strengthening and supporting the patient-physician
relationship. Since the release of the policy paper in January
2006, the ACP, American Academy of Family Physicians,
American Academy of Pediatricians and the American
Osteopathic Association have adopted a set of joint principles
based on each organization’s respective policy.
As a result, the term now used by all of these organizations is
the “Patient-Centered Medical Home” or PCMH. This model
involves a central resource – the PCMH – as the foundation
with a competent team of healthcare providers led by a
personal physician, typically a primary care doctor. The
team would include a physician with training in complex,
chronic care management and coordination, and the team
encourages active involvement by informed patients.
Widespread implementation of this model could result
in positive fundamental changes in the way that primary
care and principal care are delivered and financed. It
Provision of enhanced and convenient access to care not•
only through face-to-face visits, but also via telephone,
email, and other modes of communication;
Ongoing, coordinated medical care in partnership with•
patients and their families;
Provision of feedback and guidance on the overall•
performance of physicians and their practices;
Use of evidence-based guidelines and clinical decision•
support tools to guide decision making at the point of
care based on patient-specific factors;
Application of appropriate health information•
A voluntary recognition process to identify primary care•
and specialty medical practices that provide patient-
centered care based on the principles of the chronic care
Demonstration of the use of “best practices” to•
consistently and reliably meet the needs of patients
while being accountable for the quality and value of care
This article is an excerpt from a policy
monograph titled “The Advanced Medical Home:
A Patient-Centered, Physician-Guided Model of
Healthcare” available on the American College of
Physicians Web site at www.acponline.org.
(See “Medical Home” on page 7)
Journal of General Internal Medicine, “The Ethical Significance of Time for the Patient-
Physician Relationship”, 2005
American College of Physicians, “Medical Professionalism in the Changing Health Care
Environment: Revitalizing Internal Medicine by Focusing on the Patient–Physician
Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st
Michael S. Barr, M.D., M.B.A., FACP
Vice President, Practice Advocacy
Division of Governmental Affairs &
American College of Physicians
Jack Ginsburg, M.P.E.
Director, Health Policy Analysis &
American College of Physicians
3. A new set of criteria has been developed to recognize
physician practices as patient-centered medical homes. The
traditional medical home concept is a model of care with
long-term physician-patient relationships at the center of a
coordinated system of care.
The criteria were developed by the National Committee for
Quality Assurance (NCQA) in partnership with the Patient-
Centered Primary Care Collaborative.
Seven principles comprise the characteristics of the medical
Personal physician1. – provides first contact and
Physician-directed practice2. – one doctor leads a
team at the practice level.
Whole person orientation3. – physician coordinates
care with other healthcare providers for all stages of life
and levels of illness.
Coordinated care across all the health system4.
– this includes specialist care, subspecialty care,
hospitals, home health agencies, nursing homes, etc.
and is facilitated by technology and health information
exchange. The goal is to have the historical information
necessary to make better health decisions.
Quality and safety5. – healthcare decisions are based
on evidence-based medicine guiding decision-making
and utilization of healthcare technology.
Enhanced access to care6. – this involves new
options for communication between patients, their
personal physicians and practice staff and includes such
measures as open scheduling and expanded hours.
Reformed payment system7. – the payment structure
should be revised to support the cost for meeting the
standards of a medical home practice.
During the summit, NCQA’s Greg Pawlson, M.D., M.P.H.,
executive vice president, described the program as a
“blueprint for the patient-centered medical home” for
physicians to follow.
Pawlson also stressed that
the program would not work
without adequate payment for
physicians to cover the costs
for enhanced access to care
and communication, rewards
for higher value, expanded
and clinical support, and the
promotion of active patient and
For more information, visit the
PCPCC website at www.pcpcc.net.
Sources: American Medical News, April 9,
2007 and News Now, Nov. 7, 2007
Program Recognizes Medical Home Physician Practices
Behind the Medical
In an effort to improve patient-provider relations
and create a more efficient model of healthcare
delivery, several large employers collaborated
with the government to form the Patient-Centered
Primary Care Collaborative (PCPCC). The PCPCC
is a coalition of large national employers, health
benefits companies, trade associations, profession/
affinity groups, academic centers, healthcare quality
improvement associations and the major primary
care physician associations representing 333,000
The PCPCC promotes the patient-centered
medical home model of care and provides a forum
for healthcare stakeholders to work together to
improve the healthcare system. It also provides
education to physician practices and Congressional
representatives of the federal and state governments
on the patient-centered medical home model as a
superior form of healthcare delivery.
For more information, visit www.pcpcc.net.
atria Healthcare has been selected to enter into a
strategic relationship with Microsoft Corporation
to support HealthVault, Microsoft’s newly
launched Internet-based health platform.
HealthVault is a consumer-based product that allows
users to search and discover answers to health questions,
confidentially store information regarding their own health
and act on the information to improve their health. Data
gathered by users is secured against theft and loss through
Microsoft’s optimized security platform, and users can
designate accessibility by either a physician, hospital or
other healthcare provider.
HealthVault also allows users to upload health-related data
from numerous biometric digital devices-such as blood
pressure cuffs, heart rate monitors and blood glucose
monitors. Matria’s role in the partnership initially is to
leverage its technological expertise to gather and cleanse
disparate sources of medical data to deliver a clear and
concise personal health record to HealthVault’s users.
Says Microsoft’s Peter Neupert, corporate vice president
for the Health Solutions Group: “Matria Healthcare’s
technology solutions in total population health
enhancement have played a significant role in improving
the health of individuals.”
“When combined with Matria’s proven ability to integrate
and cleanse disparate sources of data from multiple
health information systems and identify care gaps
through products such as our Physician-Patient Care
Alerts,” says Ron Loeppke, M.D., executive vice president
and chief strategic officer for Matria, “we are confident
that HealthVault will provide consumers with the tools
necessary to help manage and improve their health.”
o maximize the reach and impact of its existing
health enhancement programs, Matria client
Becton, Dickinson and Company (BD), a worldwide
supplier of medical devices, decided to integrate a new
absence management program with its existing disease
BD first launched its disease management program with
Matria Healthcare in January 2006 and later formed
a three-way partnership with Unum Corporation – a
disability and absence management provider – in
November of the same year.
The purpose was to identify employees with chronic
conditions earlier, leverage a “teachable moment” to
educate workers about BD’s available health resources and
promote timely outreach to employees, explains Nancy
Lang, vice president of Health Enhancement at Matria
“BD was interested in Matria’s capacity to receive and
process disability claims via data feeds, use the information
to refer individuals to appropriate programs and then
provide outcomes reporting,” Lang says. “BD believes
employee health is crucial to the company’s success,
and they want to do all they can to increase employee
participation in their programs.”
At the beginning of the program, only 23 percent of
individuals applying for short-term disability reported they
were enrolled in a health enhancement program. Eight
months later, 48 percent self-reported active engagement
in a Matria program.
Other results included improved clinical outcomes across
multiple targeted chronic conditions, reduced emergency
room visits and hospital admissions, and increased
participation among employees with high acuity chronic
medical conditions. One-fifth of all disabled employees
referred for condition management were first identified at
the point of disability filing.
“No competitor has the sophisticated technological
processes that Matria has in place,” Lang says. “Processing
disability claims just gives us one more piece of data
that enhances our ability to identify employees with
chronic conditions and engage their interest in a health
BD Increases Participation In
Disease Management Programs
Through Disability Integration
Matria Partners with Microsoft on Web-based Health Tool
5. The only agency that accredits call
centers recently awarded accreditation
to Matria Healthcare Nurse24SM
company’s 24-hour nurse line service.
URAC, a non-profit, independent
accreditation agency, was so impressed
with the nurse line that they offered
three years of accreditation instead of
the usual two.
URAC gave the program a perfect score
and indicated they were impressed
with what they considered to be
excellent case reviews, strong reporting,
knowledgeable and caring nurses and
resourceful physicians. Surveyors were
particularly impressed that Matria will
be consistently auditing and making
continual improvements to its program
as it focuses on continual survey
“We strive to stay accreditation-ready
and have already identified our quality
activities for 2008,” says Tim Burke,
M.S., R.N.C., assistant vice president
of clinical operations for Matria. “We
have always had high standards, and
that starts with having a strong, highly-
experienced and highly-trained staff.
Our accreditation surveyor was really
impressed with our clinicians and
non-clinicians because of their
preparation for this accreditation.
We could not have achieved the
three-year accreditation without
the people doing the job.”
Before the accreditation,
Nurse24 was founded with
telehealth standards developed
and recommended by the American
Association of Ambulatory Care Nurses,
Burke says. This starts with a strong
management structure, 24-hour access
and the monitoring of phone calls, he
“Accreditation sets us apart from other
organizations, particularly because it
is not required,” says Carol Dall, M.S.,
R.N., director of accreditation and
external audits for Matria. “It shows
that we have gone above and beyond
expectations. The accreditation is a
badge of excellence that assures our
customers and the public that our
program provides the highest standards
of safety, quality and accountability.”
Nurse24 is a telephonic support
program that provides immediate
clinical support for everyday health
issues and questions to the entire
population. The clinical support is
available 24/7 through a toll-free
nurse line service, staffed by highly
trained, registered nurses. It offers a
cost-effective solution for participants
coping with chronic and acute illnesses,
episodic or injury-related events, and
other healthcare issues.
“When someone calls into the nurse
line, they have a problem that needs
to be addressed right away and that
makes them ready to learn,” Dall says.
“Our nurses use national guidelines
of care to help callers and then, if
necessary, refer them to appropriate
Matria programs. The nurse line can
hasten the identification process, which
is an alternative to waiting for claims.”
Peer Review Spotlight
Over the past two years,
Matria’s experts have
published more than
and impactful research
studies and articles
in the nation’s most
medical journals. Our research findings have appeared
in such prestigious publications as the Journal of
Occupational and Environmental Medicine, the
American Heart Journal, and the American Journal of
Obstetrics and Gynecology, among others.
Matria highlighted 39 important articles in a new book
to provide a glance at the industry’s significant findings.
To order your copy of Matria Insights PressBox:
Summaries, Excerpts and Abstracts of Matria Published
Articles on Disease Management, Cost Savings, Health
and Productivity, and Maternity Management, please
email your address to firstname.lastname@example.org or call
A Priority at Matria
Matria works hard to enroll
as many eligible employees
and health plan members as
we can reach, but sometimes
attracting the interest of
skeptical or hard-to-reach
individuals can be difficult.
That is why we recently
formed a participant
marketing team dedicated
solely to developing targeted messaging and handling
requests for participant communication materials.
From now on, this new team will focus exclusively on the
promotion of all print and electronic communications,
including launch, campaign, enrollment, challenge and
announcement materials for both the standard and
customized packages – all to successfully contact more
individuals and help them understand how our services
can improve their health and quality of life!
24-Hour Nurse Line Earns
n the current healthcare environment,
care is fragmented, patients are
being seen by multiple physicians,
and physicians find it difficult to stay
abreast of ever-expanding evidence-based
knowledge. Avoidable errors and safety
issues are common; health care outcomes
contrast poorly with other industrialized
nations. To make matters worse, the
healthcare system is not adequately
prepared to meet the needs of a rapidly
growing population of elderly individuals
with chronic multiple conditions.
Several new “medical home” proposals
are gaining momentum to deal with these
issues. All endorse the greater role of the primary care physician,
a patient-centered approach handled by a coordinated team of
healthcare providers, emphasis on coordinated care, improvement
in outcomes and better electronic connectivity to support these
But the medical home proposals are not without challenges. Only 28
percent of physician practices are currently equipped with electronic
medical records. Many are not capable of receiving and managing
multiple data feeds, nor do they have the staffs to support the team
approach. Other hurdles include the lack of decision support tools
and having to handle multiple payers. Despite these obstacles, the
interest is strong among payers and physicians, and there are likely
to be more evaluations and pilots over the next couple of years by
interested health plans and integrated delivery systems.
Matria has become a well-established leader in bringing patients and
physicians together with impactful, actionable health information
and is well-positioned to support the medical home concept.
Matria’s technology allows us to provide periodic automated reports
and quality care gap alerts to physicians with relevant health
information about their patients gathered from various sources and
stored in our patient electronic records. This information includes
data from medical, pharmacy, and lab claims as well as self-reported
data collected by our clinicians during the delivery of our telephonic
education, compliance monitoring and health coaching services.
Our Care Alerts and individual and population reports inform
physicians when their patients are not meeting nationally
recommended guidelines of care. The system is programmed
with technical algorithms to identify patients with health risks,
patients who have been diagnosed with chronic conditions by
other physicians, or patients with chronic conditions not receiving
national standards of care who are not accessing the system.
Everything we are doing at Matria complements what physicians
want to provide in their practices. A partnership with Matria is an
extension of their practices, allows physicians to meet the standards
of the medical home as well as improve the health and quality of
lives of their patients.
Building upon the company’s technological expertise,
Matria is now using Web technology to provide monthly
live interactive educational webinars for clients and
participants in our programs, as well as recorded webcasts
of relevant educational events. Live webinars from client
and participant sessions also are recorded as webcasts to
Matria’s Web site for later viewing.
The first monthly client webinar was held in November
on “Health & Productivity Management: How to Enhance
and Maximize Your Efforts” by Ron Loeppke, M.D.,
executive vice president and chief strategic officer for
Matria, and Thomas Parry, Ph.D., president of the
Integrated Benefits Institute (IBI).
Our second client webinar was hosted live from the Matria
Institute in January featuring Newt Gingrich, founder of
the Center for Health Transformation and former Speaker
of the U.S. House of Representatives. Newt discussed
his vision for the future of the ailing healthcare system,
stressing the important role that technology will play in
bringing the healthcare system into the 21st century.
Matria Insights via the Web also includes exciting
webcasts on the most pressing health and productivity
management issues. Now available on Matria’s Web site
is our first webcast series, “The Bottom Line: Making the
Financial Case for Health Enhancement, Parts I and II,”
in which experts from MGM MIRAGE, IBI and Matria
discuss the financial benefits of investing in health and
Matria’s participant webinars so far have featured
discussions by distinguished and highly experienced
specialist physicians on how to reduce the risk for a heart
attack or stroke, depression and pulmonary rehabilitation
for chronic lung disease. Future webinar topics include
bleeding and clotting disorders, managing work and life
disruption and smoking cessation in March.
All Matria Institute sessions are recorded and available as
webcasts following the gathering. To view the webcasts,
visit Matria online (www.matria.com) and click on
Resources, then Matria Insights. A link to the Newt
Gingrich webcast is available from the homepage. You
can’t miss it!
Medical Home Practice
Richard Hodach, M.D.,
SVP, Chief Medical Officer
7. As part of the value that Matria brings to its clients,
we participate in industry associations and
conferences. Here’s a glimpse of past and future
4th Annual Hispanic Health Professional Student
Scholarship Gala Dinner
In November, Matria showed its support for the National
Hispanic Health Foundation by participating as a sponsor
of the gala dinner, held Nov. 29 at the New York Marriott
Marquis Times Square.
IHPM Health Management Conference
March 31 – April 2, 2008
Hyatt Regency Grand Cypress
Milken Institute Global Conference
April 28-30, 2008
The Beverly Hilton
Beverly Hills, Calif.
irtually everyone agrees that the centerpiece of
a successful healthcare ecosystem is the trusted
primary care physician-patient relationship.
Unfortunately, far too many Americans do not have a
long-term primary care relationship. Moreover, for those
that do, certain realities erode the potential power of that
relationship, such as scheduling difficulty, limited visit time
with the physician, lack of data and coordination among
providers, and limited support systems available in the
When you contrast inpatient and outpatient settings, certain
powerful differences emerge. And those differences reflect
the reality that America has built the world’s best sickness-
repair ecosystem, but is just beginning to understand the
infrastructure necessary for healthcare.
So, for instance, if a patient were to be admitted to the
hospital with symptoms of a stroke, a multidisciplinary team
working off a single medical record would be mobilized and
coordinated by that primary physician. This team would
likely include laboratory and diagnostic imaging resources,
consultants, nurses, physical therapists, social workers and
Once diagnosed and treated, that patient and physician
would likely meet again in the office, typically with limited
connection to the information and stakeholders so important
to the resolution of the acute illness. To the extent there
would be an ongoing need for multidisciplinary care, with
shared, timely information producing measurably better
care, breakdowns would likely occur.
A positive step toward improved health outcomes and
reduced cost, the medical home concept requires that
primary care physicians drive the long-term coordination of
care across all settings, leveraging all the necessary assets,
including specialists, laboratory, pharmacy, social workers,
health coaches, nutritionists, etc. This is where Matria can
By aligning our nurses, registered dieticians, physicians,
social workers and health coaches around that doctor-patient
relationship, we are able to assist in driving superior care
and outcomes. Our software allows our staff to see errors of
omission and departures from well-recognized standards
of care, such as missed lab tests and non-compliance with
prescribed medication. In the absence of such support, these
errors might otherwise be missed in a world of paper medical
records. There are better days ahead as Matria, patients and
physicians drive the medical home concept to new heights!
Industry Presence A Matria Perspective:
Driving Patients Back
To the Medical Home
If you have questions or ideas for stories in our
upcoming issues, give us a call at (866) 500-4580
or email us at email@example.com.
The ACP introduced the term “advanced medical home”
to distinguish these practices and called for consideration
and testing of this model of care with four policy positions.
To read the policy, visit www.acponline.org.
The ACP believes that the advanced medical home model
– now referred to as the Patient-Centered Medical Home –
applied in the context of a revised reimbursement system
– could revitalize the patient-physician relationship;
stimulate practice-level innovation; allow practices to invest
in systems-based care and measurement of that care; and
enhance coordination of care across all domains of the
The concept has garnered significant attention from
consumers, employers, payers, disease management
companies and other stakeholders who are now working
together through the Patient-Centered Primary Care
Collaborative (www.pcpcc.net) to foster the changes
necessary – including legislation, demonstration projects,
and reimbursement reform – to help implement and test the
In addition, the National Committee for Quality Assurance
(NCQA) just released a new version of their Physician
Practice Connections’ recognition program-tailored with
guidance from the ACP, AAFP, AAP and AOA to help identify
practices that deliver care based on the Patient-Centered
Medical Home model.
Medical Home Offers Hope
(continued from page 2)
8. Share and Compare
Health & ProductivityThe latest health & productivity news brought to you by Matria SPRING 2008
In the last issue, we asked you if your organization is actively involved in improving health literacy in
America and, if yes, to indicate types of involvement. One hundred percent of our respondents said yes
to the first question while 80 percent said they invest in health enhancement.
1. My organization is actively involved in health
literacy in America.
2. If yes, that involvement includes the following:
Cost of Maternity
1 in 3 pregnant
for preterm &
= $6.6 billion
such as Health Enhancement,
wellness and disease
Partnering with other
organizations in health
literacy improvement efforts
Cost of NICU
such as Health Enhancement,
wellness and disease
Partnering with other
organizations in health
literacy improvement efforts