Patient Centered Medical Home Dec 2014 Phytel

Outcomes in the Patient-Centered Medical HomePaul Grundy MD, MPHFounding President of the PCPCCIBM Director, Healthcare Transformation

@Paul_PCPCChttps://twitter.com/Paul_PCPCC

40% of commercial in-network payments are value-based … up from 11% 2012.

Half of these payments are “at

risk” and half are upside only

Paying for Value

Transformation is Here • HHS to spend $840 million on readying practices for value-based pay,

(part of the $10 Billion) • The Transforming Clinical Practice Initiative will invest $840 million over four

years to support 150,000 clinicians, group practices health systems and medical societies

• It will provide a combination of incentives, tools and information to encourage doctors to team with peers and others to transition to value-based services.

• Momentum is building toward value-based payment methods, this initiative hopes to leverage the success of leading practices, health systems and professional organizations to coach others in how to best move to value-based reimbursement. It fits well into the broader federal strategy.

ARE YOU READY!!!!??

Medicare's Chronic Care Management Payment Part of Payment Reform for Primary Care

A practice that already sees 200 Medicare patients who meet the criteria could gain $100,000 in revenue a year.

But to bill for the fee, there are requirements:•the practice must use a certified electronic health record (EHR)•the practice must offer 24-hour access to staff, who must have EHR access•each patient must have an assigned practitioner•care must be coordinated during transitions to and from hospitals and specialists•practices must create a comprehensive care plan that features medication management and outside

social services, as needed. A staff person must spend 20 minutes on this each month.•Practice must have patient engagements tools to remind, follow up and manage medication.

Section 3021 .

– BUT where the delivery system works, a patient is in a trusting relationship with a healer who is a comprehensivist with DATA in charge.

In much of the world, no one is in charge…and the result is the most wasteful and unsustainable.

Empowered by Data

The System Integrator

Creates a partnership across the medical neighborhood

Drives PCMH primary care redesign

Offers a utility for population health and financial management

Away from Episode of Care to Management of PopulationWITH DATA

Community Health

Population

HealthSystem Integrator

PatientExperien

ce

Per Capita Cost

Public Health

36.3% Drop in hospital days32.2% Drop in ER use12.8% Increase Chronic Medication use -15.6% Total cost 10.5% Drop Inpatient specialty care costs 18.9% Ancillary costs down 15.0% Outpatient specialty downSource: Outcomes of Implementing Patient-Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US - PCPCC Oct 2012

Smarter Healthcare

9.9% lower rate of adult ER visits27.5% drop in adult ambulatory care sensitive inpatient stays11.8% lower rate of adult primary care sensitive ER visits 8.7% lower rate of adult high-tech radiology usage14.9% lower rate of pediatric ER visits21.3% lower rate of pediatric primary-care sensitive ER visits

Michigan Blues’ PCMH program shows statewide transformation of care in year 6

4,022 primary care doctors at 1,422 practices caring for more than 1.2 million BCBSM members

USA 2012

Ogden UT

“Mobile First” Patient Consumer

…moving beyond Flexner --- Driven by Actionable, Personalized Data

“The value of experience is not in seeing much, but in seeing wisely.”

-William Osler

Dr. Abraham Flexner

PreventiveMedicine

MedicationRefills Acute Care

Nursing

Test Results

Master Builder

DOCTOR

Source: South-central Foundation, Anchorage AK

BehavioralHealth

CaseManager

MedicalAssistants

Chronic Disease

Monitoring

Practice Transformation Away from an Episode of Care

Source: South-central Foundation, Anchorage AK

PCMH Parallel Team Flow Design*

MedicationRefills

ChronicDisease

MonitoringTest

Results

AcuteCare

PreventiveMedicine

Point of Care Testing

Acute Mental Health

Complaint

ChronicDisease

ComplianceBarriers

HealthcareSupportTeam

Behavioral Health

MedicalAssistants

CaseManager Clinician

* the glue is real data, not a

doctor’s brain

Healthcare Will TransformFamily Medicine for America’s Health

Data Driven

Every person has a plan

Team based

Managing a population down to the person

Today’s Care PCMH CareMy patients are those who make appointments to see me

Our patients are the population community

Care is determined by today’s problem and time available today

Care is determined by a proactive plan to meet patient needs with or without visits

Care varies by scheduled time and memory or skill of the doctor

Care is standardized according to evidence-based guidelines

Patients are responsible for coordinating their own care

A prepared team of professionals coordinates all patients’ care

I know I deliver high quality care because I’m well trained

We measure our quality and make rapid changes to improve it

It’s up to the patient to tell us what happened to them

We track tests & consultations, and follow-up after ED & hospital

Clinic operations center on meeting the doctor’s needs

A multidisciplinary team works at the top of our licenses to serve patients

Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

Superb Access to Care

Patient Engagement in CareClinical Information Systems, Registry Care Coordination

Team Care

Communication Patient Feedback

Mobile easy to use and Available Information

Defining the Care Centered on Patient

Primary Care Capacity: Patient Centered Medical Home

Operational Care Coordination: Embedded RN 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 (quality, appropriate utilization and patient satisfaction)

Achieve Supportive Base for Risk, and Bundled Payments with Outcome Measurement and Health Plan Involvement

Trajectory to Value-Based Purchasing: Achieving Real Care Coordination and Outcome Measurement

Source: Hudson Valley Initiative

HIT Infrastructure: EHRs and Connectivity

Payment reform requires more than one method, you have dials… adjust them!!!

“fee for health”“fee for value” “fee for outcome”“fee for process” “fee for belonging“fee for service” “fee for satisfaction”

Benefit Redesign - Patient Engagement Different Strategies for Different Healthcare Spend Segments

% Total Healthcar

e Spend

% of Members

Those who are well or think they are well

Those with chronic illness

Those with severe, acute illness or injuries

Public Health

Prevention

Specialists

PCMH 2.0 in Action

Community Care TeamNurse CoordinatorSocial Workers

DieticiansCommunity Health Workers

Care Coordinators

Public Health Prevention HEALTH WELLNESS

Hospitals

PCMH

PCMH

Health IT Framework

Global Information Framework

Evaluation Framework

Operations

A Coordinated Health System

How many patients can you see?How many patients’ problems can you solve?

How can we encourage and convince patients to get required prevention?How can we create systems that significantly increase that patients get required prevention?

How often should a physician see a patient to optimally monitor a condition?What is the best way to optimally monitor a condition?

Asking New QuestionsFromTo

FromTo

FromTo

*Source: 2014 Kaiser Permanente Jack Cochran

Need to move from traditional care provider to health partnerIf you do not choose innovation (play a better game) you will be forced into disruption (game changed for you). An honest assessment is to see it coming and recognize that in some places, it is already there

Millennials are already finding the convenience, economics and technology in virtual health compelling -- so you can chose innovation or disruption

Virtual access will become a required defensive strategy. The primary care team can be engaged in virtual augmented relationship to avoid the loss of the relationship

A Choice for the Future

Thank you

Apply new insights from interactions

and outcomes to enable continuous

transformation

LEARNING

Identify and influence individuals and

populations, and recognize intervention

opportunities

INTERVENTION

COORDINATIONDeliver care and monitor

progress across clinical and social requirements

COLLABORATIONAssess and engage individuals and stakeholders to drive individualized care plans

Drive evidence-based andstandardized care planning

KNOWLEDGE

WELLNESS

A comprehensive approach helps reduce costs while improving care