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1
Michigan Hospital
Association
Board Governance Meeting
Mary Beth Bolton, MD, FACP
October 24, 2010
2
Patient-Centered Medical Home:
A Critical Opportunity
To improve current and future performance in many areas:
• Quality of care and service for the patient
• Efficiency, effectiveness and cost of health care services
• Informed choice and access to health care services
• Patient satisfaction with their overall healthcare experience
3
The Patient-Centered Medical Home
• The patient centered medical home concept is supported
by a large multi-stakeholder group reflecting a broad range
of physician professional associations, major employers,
major insurers and others that have formed an organization
called the “Patient Centered Primary Care Collaborative”
• Over several hundred members including: General Motors, Delphi,
Walgreens, HAP, AIAG, IBM, AARP, Blue Cross Blue Shield Assoc,
United Healthcare, CIGNA, AETNA, Wellpoint, Medical Network One,
most of the primary care focused major physician associations and
two major health systems (Geisinger and University of Pittsburgh
Medical Center)
• The basis for support is the increasing evidence that care
delivery through primary care physicians increases the
value of care delivered, as reflected in improved quality and
reduced expense
4
The Value of Primary Care
• Evidence suggests that access to high quality primary care results
in lower overall health care costs and lower use of higher cost and
lower value services, i.e., specialists, ER, inpatient care
– Adults with a primary care physician rather than a specialist as their
personal physician had a 33% lower annual adjusted cost of care and
19% lower adjusted mortality
– Increased primary care to population ratios are associated with
reduced hospitalization rates for 16 ambulatory sensitive conditions
– Health care costs are higher in regions with higher ratios of specialists
to generalists
• Primary care currently operates on a transaction-based model and
reimbursement does not recognize the value of (and specifically
reimburse for) individualized, comprehensive care management
– There is a significant reduction in physicians in primary care specialists
with associated poor access to primary care for patients and escalation
of care into higher cost settings
Source: Paul Grundy MD, MPH, Director, IBM Healthcare Technology and Strategic Initiatives, “Patient Centered-
Primary Care Collaborative,” NCQA Policy Conference, December 7, 2007
5
5
Also documented in Patient Centered Medical Home, Maine Center for Public Health, October 15, 2008, by Josh Cutler, MD,
Director
6
6
7
0
1000
2000
3000
4000
5000
6000
7000
1
9
8
0
1
9
8
2
1
9
8
4
1
9
8
6
1
9
8
8
1
9
9
0
1
9
9
2
1
9
9
4
1
9
9
6
1
9
9
8
2
0
0
0
2
0
0
2
2
0
0
4
United States
Germany
Canada
France
Australia
United Kingdom
Average spending on health per capita ($US PPP)
Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care Expenditures: What
Are the Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data
8
76
81
88
84
89 89
99 97
88
97
109 106
116 115 113
130
134
128
115
65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110
0
50
100
150
France
Japan
Australia
Spain
Italy
Canada
NorwayNetherlands
Sweden
Greece
AustriaGerm
any
Finland
New
Zealand
Denm
ark
United
Kingdom
Ireland
Portugal
United
States
1997/98 2002/03
Countries’ age-standardized death rates, list of conditions considered amenable to health care Source: E. Nolte and C. M. McKee, Measuring the Health of
Nations: Updating an Earlier Analysis, Health Affairs, January/February 2008, 27(1):58–71
USA worse/19
37th
by WHO
9
Patient-Centered Medical Home
Element Explanation Comments
Personal physician Ongoing relationship with a personal physician: first contact, continuous and comprehensive care
Members are assigned to a PCP
at all times
Physician directed medical practice Personal physician leads team at practice level that collectively take responsibility for ongoing care of patients
Team effectiveness is evident in
higher / improved performance.
Whole person orientation Providing or arranging all the patient’s health care needs – preventive, acute, chronic – at all stages of life
PCP accountability for quality
and efficient care
Coordinated / integrated care Across all providers and settings and the patient’s community. Facilitated by registries, IT, health info exchange
to assure that patients get the indicated care when and where they need it in a culturally and linguistically
appropriate manner
Documented use of registries
and / or HAP MHM.
Clinician/group CAHPS
Quality and safety Are hallmarks of the patient-centered medical home
HEDIS quality & safety
measures exceed threshold
Enhanced access to care Open scheduling, expanded hours and new options for communications between patients, personal physician
and office staff
Office hours beyond 9-5 M-F
Non-traditional hours &
weekends
Open access scheduling
E-visits
Payment recognizes added value to
patients
More rational (and higher) payment for primary care
Fee schedule, pay-for-
performance, public recognition
National Consensus Principles – AAAFP, AAP, ACP, AOA (March 2007)
These principles are recognized and supported in NCQA’s updated Physician Practice Connections recognition program and the BCBSM PGIP program
10
Michigan Primary Care Consortium
(MPCC)
• The Michigan Primary Care Consortium convened a
group of representatives from insurance
companies, health plans, and professional
associations to develop statewide consensus on
the PCMH definition, identification, and metrics
• The group determined the joint principles of:
– Personal Physician
– Physician directed medical practice
– Whole person orientation
– Care that is coordinated and/or integrated
– Quality and safety
– Enhanced Access
– Payment changes to support primary care physicians
11
Michigan Primary Care
Consortium
• The group then added the following
Michigan specific footnotes:
– Patient-centered model of care recognizes the
patients as stewards of their own health
– Personal physician may be of any specialty, but the
practice must meet all requirements defined as
PCMH
– Clinical outcomes, safety, resource utilization and
clinical and administrative efficiency are consistent
with best practices
– Transformational change in healthcare financial
incentives should occur simultaneously with,
proportionally to, and in alignment with PCMH
adoption
12
Significant Joint Principles of PCMH
• Enhanced access to care is available through
systems such as open scheduling, expanded
hours and new options for communication
between patients, their personal physician and
practice staff
• Payment appropriately recognizes the added
value provided to patients who have a PCMH
– It should support adoption and use of health information
technology for quality improvement
13
Michigan Primary Care Consortium
(MPCC) Payer Committee was instituted in
2009
• Our goal is to align Patient Centered Medical
Home (PCMH) criteria and metrics amongst
major insurers and health plans in Michigan,
including Medicaid (now also with the CMS
grant to Michigan if funded)
• Respond to the crisis in primary care in
Michigan, in an organized and collaborative
way by bringing together the Medical
Directors of the major Michigan health plans
and engage Medical Society leadership
(MSMS, MOA and Michigan Association of
Health Plans)
14
MPCC Payer Committee Participants in 2009 -
2010
– Blue Cross Blue Shield of Michigan
– Health Alliance Plan
– Health Plus
– Medicaid leadership and MDCH
– Michigan Association of Health Plans
– Michigan Osteopathic Association
– Michigan State Medical Society
– Molina Healthcare
– Priority Health
– Physician leaders from MPCC steering
committee
– MPCC leadership: Carol Callaghan
15
2009 meeting highlights:
• Anti trust concerns were addressed by request to the Attorney
General who agreed we were meeting in “the best interest of
the well being of the citizens of Michigan” and that specific
payment levels would not be discussed.
• Committee agreed on the Joint Principles of the Patient
Centered Medical Home (PCMH) of the MPCC
• Supported development of all payer metrics and formulated a
PCMH metrics subgroup
• Evaluated other state and regional initiatives that had been
implemented and identified areas of success that could be
replicated
• Reviewed the medical literature on PCMH, NCQA standards,
and other national groups to define which features of PCMH
had the greatest impact on clinical quality and cost.
Michigan Primary Care Consortium
(MPCC) Payer Committee
16
MPCC payer committee supported three initial
elements of PCMH and how they would be
measured for 2010 primary care physicians
incentive:
• Expanded practice hours: expanded appointment hours and access to care
(before 8 a.m. after 5 p.m. M -F and weekend access).
• Electronic prescribing in the practice setting and evidence of consistent use
(attestation or documentation).
• All Payer patient registry - with Michigan Quality Improvement guidelines
(MQIC) used to identify gaps in care for all patients in the physician’s practice.
• 2011 metrics will be expanded to include
– Decision support rules
– Emergency department (ED) use
– Key patient demographics
• Race
• Ethnicity
• Preferred language
17
Goal MPCC payer committee for
2011 and 2012
• Group agreed to continue work and to meet six times
annually
• Commitment to continue to align payment for PCMH
elements consistently amongst payers and to potentially
share assessments of compliance of the practices amongst
plans to reduce administrative burden to practices and health
plans
• Continue to align grant dollars, payer payment and NCQA
certification criteria for Patient centered medical home
payment
• Provide leadership and coordination to identify technology
solutions for physician practices to implement Electronic
prescribing and all payer registries
• Identify and share best practices found nationally or in
Michigan with physician practices to accelerate improvement

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Michigan Hospital Association Governance meeting

  • 1. 1 Michigan Hospital Association Board Governance Meeting Mary Beth Bolton, MD, FACP October 24, 2010
  • 2. 2 Patient-Centered Medical Home: A Critical Opportunity To improve current and future performance in many areas: • Quality of care and service for the patient • Efficiency, effectiveness and cost of health care services • Informed choice and access to health care services • Patient satisfaction with their overall healthcare experience
  • 3. 3 The Patient-Centered Medical Home • The patient centered medical home concept is supported by a large multi-stakeholder group reflecting a broad range of physician professional associations, major employers, major insurers and others that have formed an organization called the “Patient Centered Primary Care Collaborative” • Over several hundred members including: General Motors, Delphi, Walgreens, HAP, AIAG, IBM, AARP, Blue Cross Blue Shield Assoc, United Healthcare, CIGNA, AETNA, Wellpoint, Medical Network One, most of the primary care focused major physician associations and two major health systems (Geisinger and University of Pittsburgh Medical Center) • The basis for support is the increasing evidence that care delivery through primary care physicians increases the value of care delivered, as reflected in improved quality and reduced expense
  • 4. 4 The Value of Primary Care • Evidence suggests that access to high quality primary care results in lower overall health care costs and lower use of higher cost and lower value services, i.e., specialists, ER, inpatient care – Adults with a primary care physician rather than a specialist as their personal physician had a 33% lower annual adjusted cost of care and 19% lower adjusted mortality – Increased primary care to population ratios are associated with reduced hospitalization rates for 16 ambulatory sensitive conditions – Health care costs are higher in regions with higher ratios of specialists to generalists • Primary care currently operates on a transaction-based model and reimbursement does not recognize the value of (and specifically reimburse for) individualized, comprehensive care management – There is a significant reduction in physicians in primary care specialists with associated poor access to primary care for patients and escalation of care into higher cost settings Source: Paul Grundy MD, MPH, Director, IBM Healthcare Technology and Strategic Initiatives, “Patient Centered- Primary Care Collaborative,” NCQA Policy Conference, December 7, 2007
  • 5. 5 5 Also documented in Patient Centered Medical Home, Maine Center for Public Health, October 15, 2008, by Josh Cutler, MD, Director
  • 6. 6 6
  • 7. 7 0 1000 2000 3000 4000 5000 6000 7000 1 9 8 0 1 9 8 2 1 9 8 4 1 9 8 6 1 9 8 8 1 9 9 0 1 9 9 2 1 9 9 4 1 9 9 6 1 9 9 8 2 0 0 0 2 0 0 2 2 0 0 4 United States Germany Canada France Australia United Kingdom Average spending on health per capita ($US PPP) Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data
  • 8. 8 76 81 88 84 89 89 99 97 88 97 109 106 116 115 113 130 134 128 115 65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110 0 50 100 150 France Japan Australia Spain Italy Canada NorwayNetherlands Sweden Greece AustriaGerm any Finland New Zealand Denm ark United Kingdom Ireland Portugal United States 1997/98 2002/03 Countries’ age-standardized death rates, list of conditions considered amenable to health care Source: E. Nolte and C. M. McKee, Measuring the Health of Nations: Updating an Earlier Analysis, Health Affairs, January/February 2008, 27(1):58–71 USA worse/19 37th by WHO
  • 9. 9 Patient-Centered Medical Home Element Explanation Comments Personal physician Ongoing relationship with a personal physician: first contact, continuous and comprehensive care Members are assigned to a PCP at all times Physician directed medical practice Personal physician leads team at practice level that collectively take responsibility for ongoing care of patients Team effectiveness is evident in higher / improved performance. Whole person orientation Providing or arranging all the patient’s health care needs – preventive, acute, chronic – at all stages of life PCP accountability for quality and efficient care Coordinated / integrated care Across all providers and settings and the patient’s community. Facilitated by registries, IT, health info exchange to assure that patients get the indicated care when and where they need it in a culturally and linguistically appropriate manner Documented use of registries and / or HAP MHM. Clinician/group CAHPS Quality and safety Are hallmarks of the patient-centered medical home HEDIS quality & safety measures exceed threshold Enhanced access to care Open scheduling, expanded hours and new options for communications between patients, personal physician and office staff Office hours beyond 9-5 M-F Non-traditional hours & weekends Open access scheduling E-visits Payment recognizes added value to patients More rational (and higher) payment for primary care Fee schedule, pay-for- performance, public recognition National Consensus Principles – AAAFP, AAP, ACP, AOA (March 2007) These principles are recognized and supported in NCQA’s updated Physician Practice Connections recognition program and the BCBSM PGIP program
  • 10. 10 Michigan Primary Care Consortium (MPCC) • The Michigan Primary Care Consortium convened a group of representatives from insurance companies, health plans, and professional associations to develop statewide consensus on the PCMH definition, identification, and metrics • The group determined the joint principles of: – Personal Physician – Physician directed medical practice – Whole person orientation – Care that is coordinated and/or integrated – Quality and safety – Enhanced Access – Payment changes to support primary care physicians
  • 11. 11 Michigan Primary Care Consortium • The group then added the following Michigan specific footnotes: – Patient-centered model of care recognizes the patients as stewards of their own health – Personal physician may be of any specialty, but the practice must meet all requirements defined as PCMH – Clinical outcomes, safety, resource utilization and clinical and administrative efficiency are consistent with best practices – Transformational change in healthcare financial incentives should occur simultaneously with, proportionally to, and in alignment with PCMH adoption
  • 12. 12 Significant Joint Principles of PCMH • Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician and practice staff • Payment appropriately recognizes the added value provided to patients who have a PCMH – It should support adoption and use of health information technology for quality improvement
  • 13. 13 Michigan Primary Care Consortium (MPCC) Payer Committee was instituted in 2009 • Our goal is to align Patient Centered Medical Home (PCMH) criteria and metrics amongst major insurers and health plans in Michigan, including Medicaid (now also with the CMS grant to Michigan if funded) • Respond to the crisis in primary care in Michigan, in an organized and collaborative way by bringing together the Medical Directors of the major Michigan health plans and engage Medical Society leadership (MSMS, MOA and Michigan Association of Health Plans)
  • 14. 14 MPCC Payer Committee Participants in 2009 - 2010 – Blue Cross Blue Shield of Michigan – Health Alliance Plan – Health Plus – Medicaid leadership and MDCH – Michigan Association of Health Plans – Michigan Osteopathic Association – Michigan State Medical Society – Molina Healthcare – Priority Health – Physician leaders from MPCC steering committee – MPCC leadership: Carol Callaghan
  • 15. 15 2009 meeting highlights: • Anti trust concerns were addressed by request to the Attorney General who agreed we were meeting in “the best interest of the well being of the citizens of Michigan” and that specific payment levels would not be discussed. • Committee agreed on the Joint Principles of the Patient Centered Medical Home (PCMH) of the MPCC • Supported development of all payer metrics and formulated a PCMH metrics subgroup • Evaluated other state and regional initiatives that had been implemented and identified areas of success that could be replicated • Reviewed the medical literature on PCMH, NCQA standards, and other national groups to define which features of PCMH had the greatest impact on clinical quality and cost. Michigan Primary Care Consortium (MPCC) Payer Committee
  • 16. 16 MPCC payer committee supported three initial elements of PCMH and how they would be measured for 2010 primary care physicians incentive: • Expanded practice hours: expanded appointment hours and access to care (before 8 a.m. after 5 p.m. M -F and weekend access). • Electronic prescribing in the practice setting and evidence of consistent use (attestation or documentation). • All Payer patient registry - with Michigan Quality Improvement guidelines (MQIC) used to identify gaps in care for all patients in the physician’s practice. • 2011 metrics will be expanded to include – Decision support rules – Emergency department (ED) use – Key patient demographics • Race • Ethnicity • Preferred language
  • 17. 17 Goal MPCC payer committee for 2011 and 2012 • Group agreed to continue work and to meet six times annually • Commitment to continue to align payment for PCMH elements consistently amongst payers and to potentially share assessments of compliance of the practices amongst plans to reduce administrative burden to practices and health plans • Continue to align grant dollars, payer payment and NCQA certification criteria for Patient centered medical home payment • Provide leadership and coordination to identify technology solutions for physician practices to implement Electronic prescribing and all payer registries • Identify and share best practices found nationally or in Michigan with physician practices to accelerate improvement