Transcript Futurescan - West Virginia Chapter

Patient-Centered Medical Home
WVACHE Spring Educational Offering
April 20, 2012
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Moderator
David K. McClure, FACHE
V.P. Operations
Camden Clark Medical Center
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Goals and Objectives
• Heightened your awareness of:
– Transformation to Accountable Care
– Overarching aspects of a patient-centered
medical home (PCMH)
– Components of a PCMH and the use of
clinical integration, IT and risk sharing
– Developing evidence-based medical practices
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Healthcare Policy:
The Future of
Health Reform
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Healthcare Policy:
At Risk and Accountable
Health care reimbursement will come from “at
risk” payment strategies or through an
Accountable Care Organization.
• Move forward on an IT infrastructure that can reliably
reflect clinical and administrative functions.
• Look for ways to reduce waste and improve
processes.
• Develop partnerships in the medical marketplace.
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Payment: Paying for More
An increasing number of caregiver activities that
can potentially reduce costs and manage
chronic disease (e.g., telephone or e-visits) will
be reimbursed.
• Make sure that information and management systems can
reliably capture these unconventional activities.
• Promote these encounters by educating patients and
caregivers on the convenience and value of these
activities.
• Help physicians successfully integrate these activities into
their practices.
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Integration: Codependence
The Affordable Care Act’s promotion of Accountable
Care Organizations (ACOs) and bundled payment
mechanisms will mean that all healthcare providers will
be codependent.
• Reduce costs, including admissions and diagnostics that
don’t contribute to positive outcomes.
• Develop relationships that integrate clinical functions and
align incentives.
• Evaluate your organization’s readiness to become an ACO
and or partner with an ACO.
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Integration
The anticipation of healthcare reform has
already prompted many healthcare providers to
seek close alliances with hospitals and
collaborate with insurers. This trend will only
intensify.
• Be sensitive to the patient’s needs
• Create programs that incentivize quality and
productivity.
• Develop or expand leadership opportunities.
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Integration: Broader Missions
With more physician partners, hospitals and
insurers will expand their mission statements to
include care in pre- and post-hospital settings.
• Engage your organizations board in setting a broader
agenda.
• Investigate risk sharing regarding care rendered
outside the acute-care hospital.
• Consider affiliations with other systems in order to
diversify services and gain access to capital.
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Practice Management Skills
Hospitals, insurers and Physicians will need the
knowledge and skills to manage and coordinate
healthcare practices.
• Work with physicians to develop an infrastructure that
tracks and drives clinical performance.
• Expand physician leadership and training
opportunities.
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Primary Care: Impact of Reform
The development of Primary Care Medical
Homes and Accountable Care Organizations will
result in tighter clinical integration between
hospitals, primary care and specialty care.
• Monitor federal regulations and the results of
demonstration projects closely.
• Make sure information systems can reliably integrate the
clinical and management functions.
• Work with physician leadership to ensure the medical staff
is up to date on guidelines and other care standards.
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Primary Care:
Unprecedented Demand
The already growing demand for primary care
services will increase dramatically in 2014, the
year that the Affordable Care Act expands
coverage.
• Work with educational institutions and provide
scholarships or tuition assistance to primary care students
in exchange for future service.
• Develop partnerships with other community providers
(e.g., FQHCs) that employ primary care physicians.
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Primary Care:
Reliance on Extenders
Within the next few years, the bulk of primary
care services will be provided by clinical
extenders. Insurers will reimburse these
services.
• Re-examine the traditional ratios and roles of PAs and
NPs to physicians.
• Help physicians learn to collaborate with physician
extenders to ensure continuity of care.
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Primary Care: New Models
Demand for traditional primary care services will
continue to outpace supply in the foreseeable
future, necessitating the development of new
models and approaches.
• Work with nursing leadership to ensure nurses are
practicing to the full extent of their education and
training.
• Monitor trends in education and public policy.
• Look for novel approaches and ways that IT can
extend the reach of primary care providers.
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PCMH:
Health Care Organization
Perspective
Martha Carter, CNM, MBA
CEO
FamilyCare HealthCenter
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Triple Aim
• Improve the health of the population;
• Enhance the patient experience of care
(including quality, access, and reliability);
and
• Reduce, or at least control, the per capita
cost of care
Institute for Healthcare Improvement. (2011). The IHI Triple Aim.
Retrieved from
http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx
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Overarching Changes
• Locus of control shifting more to patient
• Providers and provider organizations
increasingly accountable for patient health
outcomes and cost of care
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PCMH Standards
•
•
•
•
•
•
Enhance access and continuity
Identify and manage patient populations
Plan and manage care
Provide self-care and community support
Track and coordinate care
Measure and improve performance
NCQA. (2011). Patient-Centered Medical Home. NCQA.
Retrieved from
http://www.ncqa.org/tabid/631/default.aspx
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Medicare ACO Shared Savings Program
Quality Measures
• Patient/caregiver experience (7 measures)
• Care coordination/patient safety (6 measures)
• Preventive health (8 measures)
• At-risk populations (12 measures)
ACOs are eligible for shared savings only if
also meeting quality goals (phased in over 3
years)
Centers for Medicare & Medicaid Services. (2012, April 6). Shared Savings Program. Retrieved from
https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram/01_Overview.asp#TopOf
Page
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Change = Challenge
• How to design primary care delivery to be more
efficient and reach more people
• How to use IT to manage care of individuals and
of populations
• How to develop relationships with patients to
influence health decisions
• How to develop inter-agency relationships to
improve care and reduce cost
• How to realign goals with reimbursement
• How to finance the necessary changes & maintain
financial stability in transition
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The health care system is in transition
and we have a foot in both worlds
Pay for
Volume
?
Pay for
Quality
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Change = Opportunity
• Develop body of evidence to show what
works
• Reduce perverse incentives that support
high-cost care
• Enhance roles of health care team
members
• Explore new models of coordinated care
• Design models of accountable care
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PCMH:
An Insurers Perspective
Linda Weiland
VP, Provider Network Innovations & Partnerships
Highmark West Virginia
Agenda
• Current healthcare landscape
• The power of the accountable care
delivery models: Patient Centered
Medical Home - and Partnering
(Healthcare Providers – Patients- Payers)
to Transform Care Delivery
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Today’s Underlying Problem
The USA spends significantly more than
any other industrialized nation on health
care.
“
The USA spends significantly more than any other industrialized
nation on health care.
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The U.S. has the highest per capita public and % GDP spend- nearly 25 times the
average of other industrialized nations, and yet the poorest outcomes in mortality and
cancer survival rates.
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The current healthcare delivery system and mode of operation is
unsustainable. Spending on healthcare in the United States is
growing at a rate of 6–8%.
Uncontrolled costs=> Care Fragmentation=> Waste=>
Duplication=> Preventable Errors – Poor Quality and Care
Outcomes
Impetus of the Reform Agenda
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Illness- Wellness Assessment
2010
Healthy
50% of Population
7% of Cost
Stabile
30% of Population
22% of Cost
At Risk
10% of Population
19% of Cost
Chronic Comorbidity
7% of Population
23% of Cost
Advanced Illness
3% of Population
29% of Cost
PCPs are the foundation of the healthcare
delivery system
Patient Centered - PCP Directed
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Triple Aim Goals : Population and Individual Health, Reduced per
capita costs (Value), Improved care experience and access to care
for patients and Improved provider satisfaction and engagement.
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PCMH is a care delivery transformation focused on providing high-quality, safe,
continuous, coordinated, comprehensive care, through a partnership between
patients and their personal health care team
Current Model
Episodic Care- Illness/complaint oriented
Siloed practice operations- limited
communication
Patient- Passive, limited activation in their
care
Wide variation in practice patternsphysician preference based
PCMH Model
Coordinated Care focused on long term
healing – wellness relationships
Physician champion-led team accountable for
all patient care needs; Continuous
communication among providers, patients,
families
Patient – Active, Engaged participant in care
decision making (Shared Decision Making) .
Patient feedback sought/elicited with goal of
service and meeting expectations.
Evidence Based Medicine and clinical support
tools inform consistent decision making .
Payment- procedure based with volume
rewarded.
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Payment – Value based, performance
measurement based and outcomes based.
Highmark is committed to
partnering with practice partners to
achieve Patient Centered Medical
Home
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transformation
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Mutual Goals and
Aligned Incentives
At full scale (2015-2016), the PCMH Model is anticipated to
reduce medical spend of attributed Highmark members by 9.1%
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Patient Centered Medical Home is the foundational building block to
redesign the healthcare system.
Target
Highmark Objectives
Appropriately Reduce Medical Costs and
Utilization
Reduce medical cost trend by focusing on waste,
error, fragmentation in system (e.g. redundant,
unnecessary care)
Improve Quality of Care
Improve and sustain quality of care patient
receives; Decrease practice variation
Improve Care Outcomes
Reduce medical cost trend by preventing/
delaying the progression of diseases and chronic
conditions
Patient Satisfaction and Engagement
Increase patient satisfaction with care delivered
and informed activation in their healthcare
Establish technology infrastructure, foundation
Path forward – Impact Medical “Neighborhood”- and capabilities to develop Accountable Care
Continuum of Care
Organizations and other new care delivery
models
The goal of the PCMH is to effectively manage medical
costs, while improving care quality and activating
patients in their healthcare
Lessons Learned
Transforming Care Delivery is difficult and complex
Must address fragmentation and preventable waste
Must align incentives for all stakeholders: Patients, Employers,
Providers, Payers
Must leverage data and information – Meaningful Use of technology
(eMR, eRX, HIE, and Payer support)
Must leverage transparency and communication among all
stakeholders
The Cultural Change for ALL Stakeholders to Transform
Care Delivery – Requires “ALL IN” Team Based
Partnerships
Providers – Motivated and willing to redesign care delivery and
coordinate care
Patients/Healthcare Consumers – Actively engage in their care, healthy
outcomes, informed care decision making : “Value Based Decision
Making”
Employers – Employee education, engagement and incentives
Health Plans-Payers – Information/transparency, Provider partnerships
and support- active collaboration to support accountable care
transformation, payment reform- Value Based Payment Models and
Member Benefit Designs
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PCMH:
A Physicians Perspective
Sarah Chouinard, M.D.
Medical Director
Community Care of WV
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“Even small healthcare institutions are
complex, barely manageable places. . .
Large healthcare institutions may be the
most complex organizations in human
history.”
Peter Drucker
Post-Capitalist Society. New York, Harper and Row, 1993
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