PCPCC Medical Home update, April 2010

Edwina RogersExecutive Director

Patient Centered Primary Care Collaborative601 Thirteenth St., NW, Suite 400 North

Washington, D.C. 20005Direct: 202.724.3331Mobile: 202.674.7800

[email protected]

Patient Centered Primary Care Collaborative

and the National Patient Centered Medical Home Movement

1

Overview of Activity

• 27 Multi-stakeholder and other Pilots in 18 States

• 44 States and the District of Columbia Have Passed over 330 Laws and/or Have PCMH Activity

• Medicaid and Medicare Activity 2

3

Blue Cross Blue Shield Plan Pilots

(As of March 2010)

Pilots in planning phase for 2010 implementation

Multi-Stakeholder demonstrationPilot activity in early stages of development

Pilots in progress

There are 37 States Working to Advance Medical Homes for Medicaid or CHIP

Beneficiaries

AK

NH

MA

ME

NJ

CTRI

DE

VT

NY

DCMD

NC

PA

VAWV

FL

GA

SC

KY

IN

OH

MI

TN

MS

AL

MO

IL

IA

MN

WI

LA

AROK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AZ

NM

ID

OR

WA

NV

CA

States with at least one effort that met criteria for analysis

SOURCE: NASHP analysis

Patient-Centered Medical HomeOverview of Pilot Activity and Planning Discussions

RI

Multi-Payer pilot discussions/activity

Identified pilot activity

No identified pilot activity – 5 States5

PCPCC Membership and Activity Overview

National Convener on the PMCH Legislative and Regulatory Advocacy Develop PCMH Policy

• More than 700 members

• 54 Executive Committee Members

• 20 Advisory Board Members

• 5 Centers

• 7 Task Forces

• 3 Annual Conferences & Summits

• Monthly Calls (National PCMH Movement Briefings, CMD, CPPI, CCE)

• Bi-Weekly Calls (CEE, CeHIA)

• National Weekly Call (Thursday, 11AM EDT)• Phone number: 712.432.3900• Passcode: 471334

• Host Regular Webinars6

The Patient-Centered Primary Care Collaborative

ACP

Providers 333,000

primary carePurchasers –Most of the Fortune 500

Payers Patients

AAP AAFP AOA

ABIM ACC ACOI AHI

IBM Ohio

General Electric

FedEx

Microsoft

Dow

Merck & Co.

Business Coalitions

BCBSA United

Aetna

CIGNA

Humana

WellPoint

Kaiser Permanente

AARP AFL-CIO National Consumers League SEIU

Foundation for Informed Decision Making

Examples of Broad Stakeholder Support & Participation

The Patient-Centered Medical Home 80 Million lives

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Geisinger

Iowa

Patient Centered Primary Care Collaborative

Five ‘Centers’ - Over 770 volunteer membersCenter for Multi-Stakeholder Demonstration: Identify community-based pilot sites in order to test and evaluate the concept; offer hands-on technical assistance, share best practices, and identify funding sources to advance adoption.

Center to Promote Public Payer Implementation: Assist state Medicaid agencies and other public payers as they implement and refine programs to embed the Patient Centered Medical Home model by offering technical assistance; sharing best practices and giving guidance on the development of successful funding models.

Center for Employer Engagement: Create standards and buying criteria to serve as a guide and tool for large and small employers/purchasers in order to build the market demand for adoption of the Medical Home model.

Center for eHealth Information Adoption and Exchange: Evaluate use and application of information technology to support and enable the development and broad adoption of information technology in private practice and among community practitioners.

Center for Consumer Engagement: Engage the consumer in awareness activities through three ways: day-to-day operations, messaging and pilots. The center will continue the use of “Patient Centered Medical Home”, but focus on how the concept and its components are communicated to the public and partner with large consumer groups to capitalize on their visibility and existing efforts.

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8

PCPCC Center and Task ForceRecent Deliverables

Value Based Insurance Design Report

Payment Reform Task Force Report

PCMH Transformation Resource Guide

Medication Management Guide

Emmi Solutions PCMH Video (soon to be available in Spanish)

Pilot Activity Tracking from CMD website

Letters to Congress Letters Regarding Meaningful

Use9

History of the Medical Home Concept The first known documentation of the term “medical home”: Standards of

Child Health Care, AAP in 1967 by the AAP Council on Pediatric Practice -- “medical home -- one central source of a child’s pediatric records” History of the Medical Home Concept Calvin Sia, Thomas F. Tonniges, Elizabeth Osterhus and Sharon Taba Pediatrics 2004;113;1473-1478

Patient Centered – IOM

“I would strongly urge the adoption of the Danish model of the Patient Centered Medical Home” -- Karen Davis, Commonwealth Fund

2010 Medical Home Wikipedia page: http://en.wikipedia.org/wiki/Medical_home

PCPCC Facebook Page

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JOINT PRINCIPLES OF THE PCMH (FEBRUARY

2007)The following principles were written and agreed upon by the four Primary Care Physician Organizations – the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association.

Principles:Ongoing relationship with personal physicianPhysician directed medical practiceWhole person orientationCoordinated care across the health systemQuality and safety Enhanced access to carePayment recognizes the value added

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ENDORSEMENTS

The PCMH Joint Principles have received endorsements from 18 specialty health care organizations:•The American Academy of Chest Physicians •The American Academy of Hospice and Palliative Medicine •The American Academy of Neurology •The American College of Cardiology •The American College of Osteopathic Family Physicians •The American College of Osteopathic Internists •The American Geriatrics Society •The American Medical Directors Association •The American Society of Addiction Medicine •The American Society of Clinical Oncology •The Society for Adolescent Medicine •The Society of Critical Care Medicine •The Society of General Internal Medicine •American Medical Association•Association of Professors of Medicine•Association of Program Directors in Internal Medicine•Clerkship Directors in Internal Medicine•Infectious Diseases Society of Medicine

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Superb

Access to Care

•Patients can easily make appointments and select the day and time.

•Waiting times are short.

•eMail and telephone consultations are offered.

•Off-hour service is available.

Patient

Engagement in

Care

•Patients have the option of being informed and engaged partners in their care.

•Practices provide information on treatment plans, preventative and follow-up care reminders, access to medical records, assistance with self-care, and counseling.

Clinical

Information

Systems

•These systems support high-quality care, practice-based learning, and quality improvement.

•Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments.

Care

Coordination

•Specialist care is coordinated, and systems are in place to prevent errors that occur when multiple physicians are involved.

•Follow-up and support is provided.

Team

Care

•Integrated and coordinated team care depends on a free flow of communication among physicians, nurses, case managers and other health professionals (including BH specialists).

•Duplication of tests and procedures is avoided.

Patient Feedbac

k

•Patients routinely provide feedback to doctors; practices take advantage of low-cost, internet-based patient surveys to learn from patients and inform treatment plans.

Publicly available

information

•Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs.

8Source: Health2 Resources 9.30.08

Defining the Medical Home

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Accountable Care Organizations

14Source: Premier Healthcare Alliance

PCPCC Payment ModelMay 2007

Care Coordination

Office Visits

Performance

Blended Hybrid Payment Model (expanding upon the existing fee-for-service

paradigm)

Key physician and practice accountabilities/ value added

services and tools

Proactively work to keep patients healthy and manage existing illness or conditions

Coordinate patient care among an organized team of health care professionals

Utilize systems at the practice level to achieve higher quality of care and better outcomes

Focus on whole person care for their patients (including behavioral health)

Perfo

rman

ce S

tan

dard

s

Incentiv

es

Incentives

Incentives

16

15

At least 14 Independent Evaluations in 11 States . . . And Growing

RI

CMS will select 8 states for the Medicare Medical Home Demonstration16

Several PCMH Evaluations Underway…

The evaluations are examining a breadth of demonstrations:• From one payer to multi-payer pilots • Involve anywhere from 5-70 primary care practices

with 28-250 clinicians • Include 27,000 -- 1,000,000 beneficiaries• Many include safety net centers, pediatric sites and

Medicaid as a payer• Variety of payment models (hybrid, PMPM, annual

comprehensive PC fee)

All of these independent evaluations have comparison groups

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PCMH Evaluations (cont.)

Key Questions Under Investigation: • What does it take to become a medical

home?• Do PCMHs improve:

• Clinical Quality?• Patients’ Experiences?• Physician/Staff Experience?• Efficiency?

• Is this sustainable/ are practices financially stable?

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Community Implications - Published Results of PCMH

Projects to Date

Group Health Cooperative of Puget Sound• 29% reduction in ER visits; 11% reduction in ambulatory

care sensitive admissions• Improvements in diabetes and heart disease care• Cost neutral after 1 year

Geisinger Health System

• 14% decrease in hospital admissions• Improvements in diabetes and heart disease care• 9 % reduction in costs• ROI greater than 2 to 1

Source: PCPCC Pilot Guide, 2009 19

Community Implications – Published Results of PCMH

Projects (cont.)

Colorado Medicaid & SCHIP

• Median annual costs $785 vs $1000• Reduction in ER visits & hospitalizations• More well-child visits (72% vs 27%)• Lower median costs for children with chronic conditions

($2,275 versus $3,404)

HealthPartners Medical Group (MN)

• 39% decrease in ER visits• 24% decrease in hospital admissions• Better diabetes and cardiac care• Reduced costs

Source: PCPCC Pilot Guide, 2009 20

Community Implications – Published Results of PCMH

Projects (cont.)

Metcare of Florida/Humana PCMH Program• Started in November 2008 & Concluded in October 2009• Studied the impact of the PCMH model in a Medicare Advantage (MA) capitated

group• Hospital days per 1000 customers dropped by 4.6 percent compared to an

increase of 36 percent in the control group• Hospital admissions per 1000 customers dropped by three percent, with

readmissions running six percent below Medicare benchmarks• Emergency room expense rose by only 4.5% for the Metcare group compared

to an increase of 17.4% for the control group• Overall medical expense for the Metcare group rose by only 5.2 percent

compared to 26.3 percent increase for the control group• Preventive breast and colorectal cancer screening was 13.3 percent and 6.3

percent higher respectively, compared to the control group• Average LDL cholesterol levels dropped by 1.8 percent, and customers with

levels below 100 (a target level) rose by 4.0 percent• Ninety-four percent of diabetic patients had an A1C level of less than nine

percent

Source: Metcare Press Release, February 23, 2010 21

Community Implications – Preliminary Findings of Other

PCMH Projects (cont.)

National Naval Medical Center Medical Home Program (Bethesda, MD)

• Started 4/1/08 – ongoing• 1 IM practice; 35,000 covered lives• PCM continuity of care increase of 33%• 20.8% decrease in network ER visits per 100 enrollees• 39.5% decrease in total annual ER visits per 100 enrollees• 40.4% decrease in total specialty care visits per 100 enrollees

Source: PCPCC Pilot Guide, 2009 22

Community Implications – Preliminary Findings of Other

PCMH Projects (cont.)

Rhode Island Chronic Care Sustainability Initiative

• Started 10/1/08; 2-3 years• 5 IM and FP practices; 28,000 covered lives• Multi-stakeholder• First nine months of program (all sites combined):

• Diabetes patients with a documented hemoglobin A1c improved from 64% to 72% • Diabetes patients with BP <130/80 improved from 18% to 30%• CAD patients on Beta blocker improved from 40% to 65% • Smokers with documented advice to quit improved from 14% to 35% Source: PCPCC Pilot Guide, 2009 23

NC Savings (FY04)Category of Service Estimated Savings from Benchmark

Inpatient $142,085,680

Outpatient $51,865,028

Emergency Room $25,944,553

Primary Care, Specialist $45,498,709

Pharmacy $(15,526,996)

Other $(5,065,238)

Totals $244,801,735

Simple Cost Avoidance

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Case Example: Louisiana Greater New Orleans Primary Care Access and

Stabilization Grant

Thirteen of the 25 organizations achieved recognition by NCQA as PCMHs at 36 clinic locations (ranging from levels 1-3), and more clinics are expected to achieve the recognition in 2009.

All organizations have implemented 24/7 access to clinician by phone and same day appointments for urgent care.

The total system volume (number of individuals served) has increased by 15% every six-month period starting March 2007 for outpatient primary and behavioral health care.

The 25 participating organizations have expanded the number of service delivery sites from 67 pre-grant to 91 today.

25Source: PCPCC 2009 Pilot Guide

Recognition Programs for PCMH Developed or Under Development

Quality Organizations PCMH Standards Activity

2010

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Standard 1: Access and CommunicationA. Has written standards for patient access and patient communication**B. Uses data to show it meets its standards for patient access and communication**

Pts

459

Standard 2: Patient Tracking and Registry FunctionsA. Uses data system for basic patient information(mostly non-clinical data)B. Has clinical data system with clinical data insearchable data fieldsC. Uses the clinical data systemD. Uses paper or electronic-based charting tools to organize clinical information**E. Uses data to identify important diagnoses and conditions in practice**F. Generates lists of patients and reminds patients and clinicians of services needed (population management)

Pts

2

33

64

321

Standard 3: Care ManagementA. Adopts and implements evidence-based guidelines for three conditions **B. Generates reminders about preventive services forcliniciansC. Uses non-physician staff to manage patient careD. Conducts care management, including care plans,assessing progress, addressing barriersE. Coordinates care//follow-up for patients whoreceive care in inpatient and outpatient facilities

Pts

3

43

55

20

Standard 4: Patient Self-Management SupportA. Assesses language preference and othercommunication barriersB. Actively supports patient self-management**

Pts

246

Standard 5: Electronic PrescribingA. Uses electronic system to write prescriptionsB. Has electronic prescription writer with safety checksC. Has electronic prescription writer with cost checks

Pts3328

Standard 6: Test TrackingA. Tracks tests and identifies abnormal resultssystematically**B. Uses electronic systems to order and retrieve tests and flag duplicate tests

Standard 7: Referral TrackingA. Tracks referrals using paper-based or electronicsystem**

Pts

7613Pts44

Standard 8: Performance Reporting andImprovementA. Measures clinical and/or service performanceby physician or across the practice**B. Survey of patients’ care experienceC. Reports performance across the practice or byphysician **D. Sets goals and takes action to improveperformanceE. Produces reports using standardized measuresF. Transmits reports with standardized measureselectronically to external entities

Pts

3

33

321

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Standard 9: Advanced Electronic CommunicationsA. Availability of Interactive WebsiteB. Electronic Patient IdentificationC. Electronic Care Management Support

Pts1214

**Must Pass Elements

NCQA PPC-PCMH Content and Scoring

Scoring: Building a Ladder to Excellence

Level 1: 25-49 Points; 5/10 Must Pass

Level 2: 50-74 Points; 10/10 Must Pass

Level 3: 75+ Points; 10/10 Must Pass

Increasing Complexity of Services

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PPC-PCMH RECOGNIZED PRACTICES BY STATE(As of 12/31/09)

0

10

20

30

40

50

60

70

80

90

AZ CA CO DC IA LA MAMD ME MI MN MO NC NH NJ NY OK PA RI TN TX VA VT WA WI

State

Nu

mb

er o

f Pra

ctic

es

PPC-PCMH Level 1 PPC-PCMH Level 2 PPC-PCMH Level 3

Source: NCQA, December 2009

PCMH Implementation Tools- Report Release“Aligning Incentives and Systems”

Promoting Synergy Between Value-Based Insurance Design and the Patient Centered Medical Home”

Makes the business value case for PCMH showing link to VBID

Case studies: Whirlpool Company, the State of Washington, the City of Battle Creek, Mich., IBM, Roy O. Martin Lumber, CIGNA, Universal American, Geisinger Health System/Health Plan, Aetna and the State of Minnesota.

Authored by the Center for Employer Engagement in partnership with the National Business Coalition on Health and the University Michigan’s Center for Value-Based Insurance Design

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Meaningful Use: Meaningful Connections

Defines health IT capabilities essential to PCMH.

Crosswalks capabilities with functional priorities supporting PCMH.

Explores how patients/consumers are currently using health IT to connect.

Representative sample of 19 case example responses from primary care providers.

Appendices include Guidelines for PCMH

Demonstration Projects Consumer Principles Consumer Toolkit

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Patient Centered Primary Care Collaborative

“Purchaser Guide” Released July, 2008

Developed by the PCPCC Center for Benefit Redesign and Implementation in partnership with NBCH and the Center’s multi-stakeholder advisory panel.

Guide offers employers and buyers actionable steps as they work with health plans in local markets - over 6000 copies downloaded and/or distributed.

Includes contract language, RFP language and overview of national pilots.

Includes steps employers can take to involve themselves now in local market efforts.

The PCPCC is holding a series of Webinars, sponsored by Pfizer, on the Purchaser Guide.

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Patient Centered Primary Care Collaborative

“Proof in Practice– A Compilation of Patient Centered Medical Home Pilot and Demonstration Projects” Released

October 2009

Developed by the PCPCC Center for Multi-stakeholder Demonstration through a grant from AAFP offering a state-by-state sample of key pilot initiatives.

Offers key contacts, project status, participating practices and market scan of covered lives; physicians.

Inventory of : recognition program used, practice support (technology), project evaluation, and key resources.

Begins to establish framework for program evaluation/ market tracking.

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PATIENT CENTERED PRIMARY CARE COLLABORATIVE

“A COLLABORATIVE PARTNERSHIP – RESOURCES TO HELP CONSUMERS THRIVE IN THE MEDICAL

HOME” RELEASED OCTOBER 2009

Included in the Guide:1. PCPCC activities and initiatives supporting consumer engagement;2. Research and examples surrounding consumer engagement in PCMH demonstrations;3. Tools for consumers and other stakeholders to assist with PCMH education, engagement and partnerships; and4. A catalogue of resources that provides descriptions of and the means to obtain potential resources for consumers,providers and purchasers seeking to better engage consumers.

Information Flow- Consumer Materials

What consumers can expect- PCMH consumer principles (brochure) Guidance to create

your own practice brochure in support of PCMH model (paper)

Four minute video for waiting room viewing; deep-dive on PCMH (Flash)

Promotes Primary Care (brochure)

Deep-dive focus on PCMH (brochure)

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On September 16, 2009 HHS Secretary Sebelius, along with Director of White House Office of Health Reform Nancy-Ann DeParle and Vermont Governor Jim Douglas, announced that the Centers for Medicare and Medicaid Services (CMS) will establish a demonstration program that will enable Medicare to join Medicaid and private insurers in innovative state-based advanced primary care initiatives.

New Medicare Demonstration

• Design will include mechanisms to assure it generates savings for the Medicare trust funds and the federal government

• Private insurers work in cooperation with Medicaid to set uniform standards for “Advanced Primary Care (APC) models”

• Provide incentives for doctors to spend more time with their patients and offer better coordinated higher-quality medical care

States Wishing to Participate in the New Demonstration Must:

• Certify they have already established similar cooperative agreements between private payer and their Medicaid program;

• Demonstrate a commitment from a majority of their primary care doctors to join the program;

• Meet a stringent set of qualifications for doctors who participate; and

• Integrate public health services to emphasize wellness and prevention strategies.

MEDICARE-MEDICAID ADVANCED PRIMARY CARE DEMONSTRATION

INITIATIVE

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Encouraging Movement White House, Senate and House

Major provisions of the Health Care Reform bills relevant to Primary Care and PCMH

State option to provide health homes for enrollees with chronic conditions. Provide States the option of enrolling Medicaid beneficiaries with chronic conditions into a health home.

Pediatric Accountable Care Organization demonstration project. Establishes a demonstration project that allows qualified pediatric providers to be recognized and receive payments as Accountable Care Organizations (ACO) under Medicaid.

Establishment of Center for Medicare and Medicaid Innovation within CMS. The purpose of the Center will be to research, develop, test, and expand innovative payment and delivery arrangements to improve the quality and reduce the cost of care provided to patients in each program.

Training in family medicine, general internal medicine, general pediatrics, and physician assistantship. Provides grants to develop and operate training programs, provide financial assistance to trainees and faculty, enhance faculty development in primary care and physician assistant programs, and to establish, maintain, and improve academic units in primary care.

Expanding access to primary care services and general surgery services. Beginning in 2011, provides primary care practitioners, as well as general surgeons practicing in health professional shortage areas, with a 10 percent Medicare payment bonus for five years.

Payments to primary care physicians. Requires that Medicaid payment rates to primary care physicians for furnishing primary care services be no less than 100% of Medicare payment rates in 2013 and 2014.

Other Items: ‘Grants to Establish Community Health Teams to Support a Medical Home Model’: the Secretary of HHS would establish a grant

program to creating the “community health team which is community-based, multi disciplinary, interprofessional teams (on the model of medical home) to increase access to comprehensive coordinated care.

Enhancing Health Care Workforce Education and Training -. Priority is given to programs that educate students in team-based approaches to care, including the patient-centered medical home. Authorization is set at $125 million. 37

CMS Activity and the PCMH

Planned Demonstrations

Medicare Medical Home Demo Status - on hold pending recent health care reform legislation

Multi-Payer Advanced Primary Care Practice Demo Status - invitation to states and solicitation in clearance

Federally Qualified Health Centers Advanced Primary Care Practice Demo Status - under development

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Test Drive the New PCPCC Website !

Soft Launch 3.18.2010 Membership Webinar

4.08.2010 -Recorded Major features include

Master calendar listing all PCPCC events

On-line and interactive Pilot Guide

User portals (consumer & patients, employer & health plans, providers & clinicians, federal & state government

Center portals and updates

http://www.pcpcc.net

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UPCOMING COLLABORATIVE EVENTS

Thursday, July 22, 2010 - Washington D.C., Stakeholder Meeting - Ronald Reagan Building and International Trade Center

Thursday, October 21, 2010 - Washington D.C., Annual Summit - Ronald Reagan Building and International Trade Center

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CONTACT INFORMATION

Visit our website – http://www.pcpcc.netTo request any additional information on the PCMH or the Patient Centered Primary Care Collaborative please contact:

Edwina RogersPatient Centered Primary Care CollaborativeExecutive Director202.724.3331 202.674.7800 (cell)[email protected] Homer Building601 Thirteenth St., NW, Suite 400 NorthWashington, DC 20005

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