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Patient-Centered Medical Home: From Concept to Reality Consumer Purchaser Disclosure Project October 17, 2007 Lisa Latts MD, MSPH VP, Programs in Clinical Excellence WellPoint, Inc More than 34 million Members Across the Country ME WI NV CA IL NY IN MO VA KY GA TX BC or BCBS licensed plans UniCare >100K members Slide 2 7/17/2015 Company Confidential | For Internal Use Only | Do Not Copy MA CT OH CO NH Patient-Centered Medical Home • Definition of an “Patient-Centered Medical Home” (PCMH): a primary care practice that provides patients with accessible, continuous and coordinated care through a patient-centered, physician-guided, cost-efficient and longitudinal approach to care • What is a Medical Home:* • Each patient has an ongoing relationship with a personal physician trained to provide first • • • • • contact, continuous and comprehensive care Physician-directed medical practice in which a team of individuals collectively take responsibility for ongoing care of patients Whole-person orientation of care for all stages of life Care is coordinated and/or integrated across all elements of the health care system Quality and safety are hallmarks of the medical home Patients have enhanced access to care through systems such as open scheduling, expanded hours and new options for communication Payment appropriately recognizes the added value to patients who have a medical home • • Medical Home is NOT: • Reemergence of capitation • Just another way to increase primary care reimbursement • Panacea for rising heath care costs • Net increase of dollars into the health care system Slide 3 7/17/2015 Company Confidential | For Internal Use Only | Do Not Copy * Adopted by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP) and the American Osteopathic Association (AOA) Why the Medical Home • Primary care is important to the delivery system – current crisis in primary care recruitment and retention • Medical home may be the (a) answer to increased quality, reimbursement and provider/patient satisfaction • Aging population & increased prevalence of chronic diseases • Current system emphasizes episodic treatment for acute care and more care, not better care; Capitation led to less care • Rising healthcare costs and gaps/variations in quality and safety • Need for better coordination of care among providers; care coordinated by a personal physician associated with better outcomes, especially in many chronic diseases • Disease management as currently exists yielding mixed results; DM activities most successful when integrated into a physician practice • Collaboration with national and local primary care providers to explore innovations and piloting PCMH models • Goals to improve safety, quality, affordability, and experience of care Slide 4 7/17/2015 Company Confidential | For Internal Use Only | Do Not Copy Collaborating for Quality and Affordability Primary Care • • • • ACP AAFP AOA AAP Purchasers Patient-Centered Medical Home Health Insurers Slide 5 7/17/2015 Company Confidential | For Internal Use Only | Do Not Copy © 2007 Blue Cross Blue Shield Association. All Rights Reserved. Patient Advocacy Groups Pilot Program Model Coordination Implementation • Implement in states across the country • Recruit variety of practice shapes and sizes • Large IPAs/ multi-specialty groups • Smaller PCP group practices • Solo and Duo Practice groups • NQCQ Practice Designation - PPC • Timing: Q1/Q2 2008 • Coordinate pilot sites with other payers, especially CMS • Critical mass of patients necessary for PCMH success • Coordinate with other programs • Pay for Performance • Disease Management • Transparency Programs • Decision-support Evaluation Care Coordination Health Information Technology Clinical Process and Outcome Measures Resource Use Cost of Care Satisfaction • Comprehensive evaluation • Discussions with Commonwealth Fund, RAND Slide 6 7/17/2015 Company Confidential | For Internal Use Only | Do Not Copy Patient-Centered Medical Home Demonstrations - BCBSA 2007-2008 Pilot Planning WA MT ME ND M T V T NH MN OR WI SD ID ID MI RI WY PA IA NE NV NV IL UT CA CO MA NY IN OH MD WV MO KS KY NJ CT D EDC VA NC TN AZ NM OK SC AR MS TX AK HI AL GA LA F L PR PR Slide 7 7/17/2015 Company Confidential | For Internal Use Only | Do Not Copy = States where PCMH demonstrations are in planning for 2008 Participation as of 10/15/07 Personal Medical Home Reimbursement and incentive structure aligned to support practice transformation, clinical process/outcomes, cost of care and satisfaction Payment Methodology Prospective Payment FFS For services currently recognized through Medicare RBRVS system; potential for additional services Pay For Quality NCQA’s PPC Recognition: •Care Coordination •Process Redesign •HIT Clinical Process and Outcomes Resource Use/ Cost of Care Evaluate Levels of Achievement Pre-Assessment of Practice Readiness Slide 8 7/17/2015 Company Confidential | For Internal Use Only | Do Not Copy Support from ACP, AAFP and AAP Satisfaction PCMH Project Questions • Practice Recruitment • Current WellPoint interest in ME, NH, • WI, VA, CO, CA Coordinate with local ACP, AAFP chapters to recruit Urban/suburban/rural Large/medium/small/single What is critical payer mass for practice • • • • PCMH Designation • NCQA PPC Program – time to get • • practices designated Who pays? Differences by level of designation attained Technical Support “Reward” for increasing levels • • • Purchaser participation • Employee incentives to use Medical Home practices? Slide 9 7/17/2015 Company Confidential | For Internal Use Only | Do Not Copy • Care Coordination Payment • All patients or just chronic disease? Which disease(s)? • How much? How often? • Opt in or opt out model for patients • Timing of Program: Start, interim evaluation, final evaluation • At least 18 month for adequate trial of effects • What to do in the interim • Evaluation • Where, What, Who and How • Definition of Success? • Key components of success vs. elements that provide no incremental value • Transparency • What if…..