Patient Centered Medical Home, A Pathway to Value-Based Reimbursement?

Confidential 2/17/2016Slide 1

Patient Centered Medical Home,A Pathway to Value-Based Reimbursement?

Industry Webcast

February 3, 2016

11:00 PT / 2:00 ET


Today’s discussion

○ Introduction and overview

○ PCMH clinical and financial

performance

○ The alternative payment landscape,

and its link to PCMH

○ Core competencies,

today and tomorrow

○ The Christ Hospital: PCMH’s role in

practice transformation

○ Q&A


Speaker introductions

David RoweSVP, Marketing & Business Development

Joe Siemienczuk, MD

Chief Medical Officer

Jacquelyn Hunt, PharmD, MS

Chief Population Health Officer

Amy Mechley, MD

Medical Director – Wellness Division,

The Christ Hospital Health Network


Enli Health Intelligence

Top-Performing Population Health Management Solution

- KLAS Research. December 2015. Population Health Management 2015: How Far Can Your Vendor Take You?

Enli


Patient Centered Medical Home

Gauging performance & progress


What is PCMH, practically?

The medical home is best described as a model or

philosophy of primary care that is patient-centered,

comprehensive, team-based, coordinated,

accessible, and focused on quality and safety [ … ]

Above all, the medical home is not a final destination

instead, it is a model for achieving primary care

excellence…Source: Patient-Centered Primary Care Collaborative


PCMH provides roadmap to advanced primary care practice

○ 7K+ practices recognized by NCQA1

○ 500%+ growth in PCMH incentive

programs—from 26 (2009) to 160 (2016)2

○ Fastest growing NCQA service PCMH certification also offered by URAC, The Joint Commission, AAAHC

1. Journal of the American Board of Family Medicine. Jan – Feb, 2016. Rosenthal. Are We Learning More

About Patient-Centered Medical Homes (PCMHs), or Learning About Primary Care?

2. Health Leaders Media. January 2016. Letourneau. PCMH Model Soaring, Despite Funding Challenges


Enli customers are pursuing PCMH more aggressively than industry at-

large

33%

50%

9%

0%

10%

20%

30%

40%

50%

60%

70%

US PCP's Enli Customers

PCMH Program Participation

Live Planning

1. Enli Health Intelligence and PYA Consultants. National CCM Provider Survey 2015

2. Enli Health Intelligence. Alternative Payment Model Participation, December 2015

○ Enli customer

participation in

PCMH networks is

>50% greater than

the national average

○ Providers

participating in

PCMH are early

adopters of

government and

commercial APMs


Evidence supports the efficacy of the PCMH model

14 peer-reviewed studies

› 10 reported on cost, 6 found

improvements

› 13 reported on utilization, 12

found improvements

› 3 reported on quality, 2 found

improvements

› 4 reported on access, 4 found

improvements

› 4 reported on satisfaction, 4

found improvements

Source: Patient-Centered Primary Care Collaborative.

January 2015. The Patient-Centered Medical Home’s

Impact on Cost and Quality


PCMH requires investment, but economics scale

○ $147,573, median annual cost1

○ $64,768 per clinician, $30 per patient1

○ 30% more, incremental short-term

impact to primary care costs2

1. Health IT Analytics. January 2016. RAND: Patient-Centered Medical Home May Cost $147K Per Year

2. JABFM. Jan – Feb, 2016. Rosenthal. Are We Learning More About Patient-Centered Medical Homes (PCMHs), or Learning About Primary Care?

3. Health IT Analytics. July 2014. CMSA Study: Patient Navigators Pay for Themselves in Two Months

○ 4%, reduction in the 30-day

readmission rate3

○ $156,000, combined savings per

navigator over six month period3

○ 2 months, average pay back period

for navigator (based upon $35K annual

salary)3


○ HHS publishes clear objectives and goals to guide payment reform. The

proliferation of commercial and government reimbursement programs to

complement team-based delivery creates sustainable models

○ PCMH certification criteria developed and updated, providing discrete

measures and offering an onramp to other programs or models

(e.g. ACO certification)

○ The Health Care Payment Learning and Action Network launches, bringing

together public and private stakeholders to accelerate the transition to

alternative payment models

Catalyzing the transition from volume to value


Alternative Payment Model Framework

Source: Health Care Payment Learning & Action Network, https://hcp-lan.org/workproducts/apm-whitepaper-onepager.pdf

https://hcp-lan.org/workproducts/apm-whitepaper-onepager.pdf


Medical homes well-positioned to pursue more aggressive payment

models

Payments in Category 3 are structured to

encourage providers to deliver effective and efficient

care

○ Primary care PCMHs are recognized within

Category 3 of HCP-LAN’s framework

○ PCMH practices have the flexibility to participate

in FFS reimbursement programs linked to quality

and value

○ PCMH practices accepting downside risk are

building competencies for population-based

payment programs


…PCMH figures prominently in the Merit-Based

Incentive Payment System (MIPS), which aims to

accelerate the nation’s shift to pay-for-performance

reimbursement and financial bonuses based on quality

achievements using the PCMH as one of the most

promising foundations for systemic improvements.

Source: Health IT Analytics. January 2016. RAND: Patient-Centered Medical Home May Cost $147K Per Year


Core Competencies, Today & Tomorrow

Teams, process, & technology


PCMH standards & requirements

Standard Summary of Requirements

PCMH 1: Patient-Centered AccessThe practice provides 24/7 access to team-based care for both routine and urgent needs of patients/families/caregivers.

PCMH 2: Team-Based CareThe practice provides continuity of care using culturally and linguistically appropriate, team-based approaches.

PCMH 3: Population Health Management

The practice provides evidence-based decision support and proactive care reminders based on complete patient information, health assessment and clinical data.

PCMH 4: Care Management and Support

The practice systematically identifies individual patients and plans, manages and coordinates care, based on need.

PCMH 5: Care Coordination and Care Transitions

The practice systematically tracks tests and coordinates care across specialty care, facility-based care and community organizations.

PCMH 6: Performance Measurement and Quality Improvement

The practice uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience.


Team-based approach to clinical care delivery

○ Clinic culture consistent with the medical home

○ Team-based training program

○ Central care team that provides support across

provider panels

○ Case management support for high-risk patients

○ Patient recognized as part of the care team


Process to proactively engage & cost-efficiently operate

Continuous loop, grounded in ongoing

operational improvement

○ Mechanisms to identify high-risk patients

○ Communication forums and information sharing

○ Escalation procedures and triggers

○ Community connections

○ Integration of behavioral health

○ Patient access


Technology platform to scale delivery model

○ Risk Stratification

● Tap clinical, claims, socioeconomic, health behavior data

● Build a population risk profile

● Define population goals consistent with contract requirements

○ Care Coordination

● Assign cohorts to programs

● Standardize workflows to minimize variation

● Assign tasks to team members according to licensure

● Forecast workload to align demand and capacity

○ Care Delivery

● Monitor, curate, and codify medical guidelines in the software

● Individualize care plans for patients

● Display opportunities complementary views across the enterprise

● Monitor and enhance patient health and engagement


Challenge: Top of license teamwork


Step 1: Filter by patients with an

appointment today


Step 2: Rapid review of the Care Plan to

support pre-visit chart prep and

morning huddle. Use Memo for

communication and tasking


Step 3: Easy-to-use tablet for collecting

patient information prior to the

visit


Step 4: Hardwire evidence-based,

patient-specific standing orders

to support the rooming process


Challenge: Test tracking & follow-up


Step 1: Providers are able to easily

adjust cancer screening intervals


Step 2: Filter by patients overdue for

cancer screening


Step 3: Automated recall letter by mail,

or via the patient portal


Step 4: Abnormal cancer work-up tracks

patients in a closed loop


Challenge: ED follow-up


Step 1: Population monitoring of

Emergency Department (ED)

visits


ED Follow Up

Step 2: ED Follow-up Module enables

efficient, standard care

coordination


Step 3: Patient goal setting includes

assessment of confidence and

barriers


Step 4: Send patient an

Asthma Action Plan by mail,

or via the EHR portal


CareManager addresses key PCMH certification standards

Standard FactorsDegree of Coverage

Product 360° Program EHR

PCMH 1: Patient-Centered Access

A. Patient-Centered Appointment Access X

B. 24/7 Access to Clinical Advise X

C. Electronic Access X

PCMH 2: Team-Based Care

A. Continuity X

B. Medical Home Responsibilities X X

C. Culturally & Linguistically Appropriate Services X

D. The Practice Team X X

PCMH 3: Population Health Management

A. Patient Information X

B. Clinical Data X

C. Comprehensive Health Assessment X X

D. Use Data for Population Management X X

E. Implement Evidence-Based Decision Support X X


CareManager addresses key PCMH certification standards (cont.)

Standard FactorsDegree of Coverage

Product 360° Program EHR

PCMH 4: Care Management& Support

A. Identify Patients for Care Management X X

B. Care Planning & Self-Care Support X X

C. Medication Management X X X

D. Use Electronic Prescribing X

PCMH 5: Care Coordination & Care Transitions

A. Test Tracking & Follow-Up X X X

B. Referral Tracking & Follow-Up

C. Coordinate Care Transitions X X X

PCMH 6: Performance Measurement & Quality Improvement

A. Measure Clinical Quality Performance X

B. Measure Reporting Use & Care Coordination X X

C. Measure Patient & Family Experience

D. Implement Continuous Quality Improvement X X

E. Demonstrate Continuous Quality Improvement X

F. Report Performance X

G. Use Certified EHR Technology X



The Christ Hospital

PCMH & practice transformation


The Christ Hospital Health Network

○ Integrated delivery system based in

Cincinnati, OH with a 555 bed acute care

hospital, 41 primary care locations, and

100+ ambulatory sites

○ Recognized national leader in clinical

excellence and patient experience

○ Focused on improving the health of the

TCH community and creating patient value

by providing exceptional outcomes,

affordable care, and the finest experiences


The evolution of primary care…


…The patient-doctor visit is no

longer the primary commodity.


○ PCMH provides a framework to

evaluate clinical effectiveness and

supports our drive for better outcomes

○ PCMH standardizes best practices

across a broad network

○ PCMH aligns delivery with emerging

reimbursement models

● Commercial payers consider PCMH network

adoption in contracts

● State of Ohio has published 5-year roadmap

for payment reform on PCMH principles

● CMS is funding payment innovation

• MDs: 200+

• Staff: 1,000+

• Clinical specialties: 25

• Locations: 100+

• EHR platform: Epic

PCMH certification vs. PCMH methodology


Value-based programs offer new revenue streams

○ Comprehensive Primary Care Initiative (CPCI)

● Multi-payer program providing primary care practices with monthly care

management payments to support practice transformation

● 4-year project: Yr. 1-2, limited risk; Yr. 3-4, base payment reduced 25% with gain

share

● Represents $10M over 4 years

● 16 of 34+ practices chosen for CPCI

○ Chronic Care Management (CCM)

● CMS-sponsored program that allows providers to bill ~$42 PMPM for non-face-to-

face care management services delivered to eligible Medicare beneficiaries

● Non-CPCI practices eligible to bill for service

● Represents $2M - $3M annually


Team-based care was not designed into the EHR

○ The EHR user experience is

transactional, not actionable

○ EHRs are designed for data

capture, not visualization or

knowledge transfer

○ Epic ill-equipped to address more

rigorous 2014 NCQA PCMH

certification requirements, or

value-based programs like

CPCI and CCM


Fewer resources

Quicker deployment

Higher functioning


Financial impact > Commercial Medicare Results

Intentional investment on focused resources leads to significant improvements

Actual Earned Potential Available Actual Earned Potential Available

3%, of

$153,160

55%, of

$236,877

Q4 2014, MA Products

Q1 2015, MA Products


Work effort > Commercial Medicare Advantage

CPCi and Non-CPCi Offices

366

118

53

93

33

417

17 12 4 7 12 12

0

50

100

150

200

250

300

350

400

450

Calls Made LMTCB Referral Placed Refused Called forReport/Waiting

Gap Closed

CPCi Offices Non-CPCi Offices


YTD Performance > Clinical Quality Measures

Clinical Quality Measure

TCHHN

Performance

All CPC Region

Performance

Influenza Immunization 24% 37%

Tobacco Use Assessment and Cessation Intervention 94.04% 70%

Colorectal Screening 59.71% 42%

Breast Cancer Screening 63.53% 41%

Diabetes Hemoglobin A1c Poor Control (low % desirable) 11.47% 12%

Diabetes LDL Control (Patients screened for LDL test) 80.07% 62%

Diabetes LDL Control (Patients LDL < 100) 45.69% 42%

Blood Pressure Control 72.93% 68%

Ischemic Vascular Disease (Patients Screened for LDL test) 74.83% 58%

Ischemic Vascular Disease (LDL controlled) 49.74% 42%





Looking forward, what’s next?

○ TCHHN has committed to invest further in CareManager,

upgrading to incorporate additional clinical evidence to address

at-risk populations

Deployment within 6 weeks

○ TCHHN is installing CareManager Central Worklist to help with

the efficiency and effectiveness of our care teams engaged in

PCMH outreach

○ TCHHN is augmenting its technology platform and delivery

model with creative strategies focused on patient engagement!


[email protected]

CareManager supports PCMH & can help put you on the path to VBR

“Enli stand outs due to its 'Knowledge to Action,' which

introduces real-time clinical decision support at the

point of care by synthesizing the latest evidence-based

guidelines and codifying them in the software”

Matt Guldin,

Chilmark Research

Clinical

decisions

informed by

evidence

mailto:[email protected]


Questions & Answers


Schedule a meeting, or stop by!

○ February 29th – March

4th

○ Upper Floor, Hall C

○ Booth #4461

Find us at HIMSS’16

http://act.enli.net/acton/fs/blocks/showLandingPage/a/2550/p/p-0047/t/page/fm/0


Thank you.

Patient Centered Medical Home, A Pathway to Value-Based Reimbursement?

Healthcare