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Marcia Nielsen
The document discusses the patient-centered medical home (PCMH) model for transforming the U.S. health system. It provides background on why the model is needed due to rising healthcare costs and issues with the current system. It describes the key components of the PCMH model including team-based and coordinated care, enhanced access, and a focus on quality and safety. The document also outlines the history and development of the PCMH model and provides examples of its implementation in different healthcare organizations and states. It discusses the role of the Patient-Centered Primary Care Collaborative in leading the transition to the PCMH model.
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Marcia Nielsen
- 1. Patient-Centered Medical Homes: Transforming the U.S.Health System Marci Nielsen, PhD, MPH Executive Director
- 2. The Patient-Centered Medical Home(PCMH) § Why? § What? § When? § Where? § Who? 2
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- 4. Health care expenditureper person by source of funding, 2007* 3,307 4,005 2,618 2,726 2,844 2,758 2,124 2,446 2,056 3,092 449 589 510 360 441 890 720 1,350 580 246 470 528 571 542 2,716 38 88 204 79 343 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 US NOR SWITZ CAN FR GER SWE AUS* UK ITA Out-of-pocket spending Private spending Public spending * 2006 Source: OECD Health Data 2009 (June 2009), Commonwealth Fund Dollars *Adjusted for Differences in Cost of Living 4
- 5. Source: Congressional BudgetOffice, “The Long Term Budget Outlook”, August 2010 Cost of health care by government 5 5
- 6. Conservatively, 30% of the annual$2.5 trillion U.S. health expenditure is estimated to be waste, equating to approximately $700B each year. Key sources of waste1 % of total medical cost that is waste Admin and system Provider inefficiencies Lack of care coordination Unwarranted Preventable conditions and avoidable care Fraud and abuse 4 - 6% 3 - 4% 1 – 2% 11 - 21% 1 - 2% 5 - 8% ~30% 1Thomson Reuters, 2011 Cost of health care “waste” 6
- 7. Need for BetterValue 7
- 8. Solutions point toprimary care Significant problems Rising healthcare costs à $2.4 trillion (17% of GDP) Gaps/variations in quality and safety Poor access to PCPs Below-average population health • PPACA and ARRA legislation • Value-based reimbursement • PCMHs • ACOs • EHR/HIE investment • Disease-management pilots • Alternative care settings • Patient engagement • Care coordination pilots • Health insurance exchanges • Top-of-license practice … Experiments underway Across 300+ studies, better primary care has proven to increase quality and curtail growth of healthcare costs … Primary care- centric projects have proven results ↑ Aging population Chronic disease 8
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- 10. Definition of PCMH 10 Comprehensive team-basedcare Patient-centered orientation Care that is coordinated Superb access to care Systems approach to quality and safety Source: www.ahrq.gov
- 11. A Change inParadigm Today Future Treating Sickness / Episodic Managing Population Fragmented Care Collaborative Care Specialty Driven Primary Care Driven Isolated Patient Files Integrated Electronic Record Utilization Management Evidence-Based Medicine Fee for Service Shared Risk/Reward Payment for Volume Payment for Value Adversarial Payer-Provider Relations Cooperative Payer-Provider Relations “Everyone For Themselves” Joint Contracting 11
- 12. Standards for PCMH p National Committee on Quality Assurance (2008) n Practice level recognition; data used by payers p Joint Commission (2011) n Primary Care Medical Home certification p URAC (2011) n Patient Centered Health Care Home Practice Achievement accreditation n Health plan focused p Accreditation Association for Ambulatory Health Care (2011) n Ambulatory care focused 12
- 13. ©2012 Foley &Lardner LLP 13 2011 NCQA PCMH Content and Scoring Standard 1: Enhance Access and Continuity A. Access During Office Hours** B. After-Hours Access C. Electronic Access D. Continuity E. Medical Home Responsibilities F. Culturally and Linguistically Appropriate Services G. Practice Team Pts 4 4 2 2 2 2 4 20 Standard 2: Identify and Manage Patient Populations A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. Use Data for Population Management** Pts 3 4 4 5 16 Standard 3: Plan and Manage Care A. Implement Evidence-Based Guidelines B. Identify High-Risk Patients C. Care Management** D. Medication Management E. Use Electronic Prescribing Pts 4 3 4 3 3 17 Standard 4: Provide Self-Care Support and Community Resources A. Support Self-Care Process** B. Provide Referrals to Community Resources Pts 6 3 9 Standard 5: Track and Coordinate Care A. Test Tracking and Follow-Up B. Referral Tracking and Follow-Up** C. Coordinate with Facilities/Care Transitions Pts 6 6 6 18 Standard 6: Measure and Improve Performance A. Measure Performance B. Measure Patient/Family Experience C. Implement Continuously Quality Improvement** D. Demonstrate Continuous Quality Improvement E. Report Performance F. Report Data Externally G. Use of Certified EHR Technology Pts 4 4 4 3 3 2 0 20 **Must Pass Elements www.ncqa.org
- 14. Health IT Infrastructure PCMHand Accountable Care: Two Sides of the Same Coin Accountable Care PCMH PCMH PCMH PCMH PCMHHospitals Public Health Shared Services Care Coordination Care Managers Specialists 14
- 15. HIT Infrastructure: EHRs and Connectivity Primary Care Capacity: Patient Centered Medical Home Operational Care Coordination: EmbeddedRN Coordinator and Health Plan Care Coordination $ Value/ Outcome Measurement: Reporting of Quality, Utilization and Patient Satisfaction Measures Value-Based Purchasing: Reimbursement Tied to Performance on Value Supportive Base for ACOs, PCMH Networks, and Bundled Payments Trajectory to Value-Based Purchasing It is a journey, not a fixed model of care 15 Source: Taconic Health Information Network & Community, 2010
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- 17. Medical Home Term in Standards of Child Health Care by Council on . Ped. Prac5ce Alma Alta Declara5on Surgeon General Koop’s Conf. Report: MH for CSHCN PCPCC Founded Medical Home and Hawaii Child Health Plan (Calvin Sia, MD) Future of Family Medicine ACP & Advanced Medical Home 1989 1967 1967-‐2006 Milestones in PCMH Development 1978 1979 2004 2002 2006 AAFP & TransforMED 17
- 18. Joint Principles of PCMH NCQA PCMH Standards and Recogni5on 2008 2006-‐Present Milestones in PCMH Development 2007 2010. 2012 Commonwealth Fund PCMH Programs State & Local PCMH Pilots Affordable Care Act Wellpoint PCMH Na5onal Launch Na5onal Business Group on Health Award 18
- 19. Shift to AccountableCare p Some people are watching and waiting… p Some people just putting a toe in… p Some people diving in head-first. p Some people are taking laps… p Some people have taken the deep plunge. 19
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- 21. PCMH Initiative Health Care Cost& Acute Care Service Measures Health Outcomes & Quality of Care Measures Horizon Blue Cross Blue Shield of New Jersey (2012) • 25% fewer inpatient hospital admissions • 26% fewer ED visits • Improved diabetes control by 8% • Screenings for breast and cervical cancer also increased by 6%. Group Health Cooperative in Seattle • 29% fewer ED visits • 6% fewer inpatient hospitalizations • Savings of $10.3 per patient per month after 21 months • Clinical quality (HEDIS) measure improvements ranged from 30-40% Geisinger (2012) • 25% fewer hospital readmissions • 53% fewer readmissions • Estimated return on investment of 2:1 • Improved quality of preventive care (74%), coronary artery care (22%), and diabetes care (34.5%) 21
- 22. PCMH Initiative Health Care Cost& Acute Care Service Measures Health Outcomes & Quality of Care Measures Vermont Blue Print for Health (2011) • Lower inpatient admissions (range of 39.7 % to 15.3%) • Lower ED admissions (range 33.8% to 2.8%) • Increase in visits for chronic care & behavioral health CareMore (2011) Medicare Advantage (California) • 24% lower inpatient admission rates (compared to Medicare average) • 15% reduction in overall health care costs • 97% patient satisfaction • Hospital stays 38% shorter • Amputation rate for diabetics 60% lower Pediatric Alliance for Coordinated Care (Boston) • Reduction of inpatient hospitalization from 57.7% to 43.2% (post implementation) • Reduction of parents’ missed work(>20 days) from 26% to 14% • Increased satisfaction with health care delivery (68.4% easier to talk with same nurse, 60.9% easier to talk with doctor, 60.5% easier to get access) 22
- 23. Robust State/local PCMH Activity p 42 Medicaid programs and numerous local/ regional activities p State maps: p NASHP n http://www.nashp.org/ med-home-map p AAP n http:// www.medicalhomeinfo.or g/state_pages/ 23
- 24. Commercial Insurance PCMH Buy-In n Wellpoint p Nationwide roll-out n BlueCross BlueShield p 39 states participating in PCMH initiative n Aetna p CT, NJ – plans to go nationwide n Humana p 10 states n UnitedHealthcare p Value-based purchasing for 50-70% of their market 24
- 25. * Health careprofessional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care. Base: Has chronic condition. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. Patient Engagement in Care Management for Chronic Condition 25 Percent reporting positive patient Engagement in managing chronic condition* 25
- 26. Percent reporting positivedoctor–patient relationship and communication* Doctor–Patient Relationship and Communication * Regular doctor always/often: spends enough time with you, encourages you to ask questions, and explains things in a way that is easy to understand. Base: Has a regular doctor/place of care. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 26
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- 28. Patient = Consumer= Voter 28 IOM (2002); modified from Dahlgren and Whitehead (1991)
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- 30. The Patient-Centered Primary CareCollaborative p Mission is to advance effective and efficient health system built on a strong foundation of primary care and patient-centered medical home (PCMH). p 1,000 members and growing; began with primary care physician associations and large employers, supported by leadership of IBM. p Joint Principles feature prominently – AAFP, AAP, ACP, and the AOA. 30 Paul Grundy, MD
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- 32. 32 32 PCPCC Re-Org Chart Boardof Directors Patient, Family & Consumer Center Care Delivery Reform Center Employer & Purchaser Engagement Center Advocacy & Policy Action Center Outcomes & Evaluation Center Special Interest Groups Event Planning (Annual Mtgs) Taskforces Publications Finance Committee Operations Committee Executive Committee
- 33. Role of TheCollaborative 33 p Lead from the front n Challenge the status quo n Drive the marketplace n Disseminate timely information n Provide networking & educational opportunities
- 34. Examples of PCPCCResources 34 Value-Based Insurance Design IT Guide Purchaser Guide Consumer Guide Source: PCPCC (www.pcpcc.net) Medication Management Guide Payment Reform Guide Participatory Engagement Guide PCMH – Evidence of Quality Practice Transformation Guide Care Coordination Guide
- 35. Contact Information www.pcpcc.net Marci Nielsen,PhD, MPH Executive Director mnielsen@pcpcc.net 35
- 36. Short video todescribe PCMH http://www.pcpcc.net/consumers- and-patients 36