Transcript Medicaid PCMH Project

Medicaid PCMH
Lonnie Robinson, MD, FAAFP
Arkansas Academy of Family Physicians
Regional Family Medicine
Beth Milligan, MD, FAAFP
Arkansas Foundation for Medical Care
Saline Med-Peds
Sheena Olson, JD
Assistant Director of Medical Services
Arkansas Medicaid
Overview
• PCMH Background/Context
• My PCMH Experience
• Medicaid PCMH Requirements
• Questions and Answers
Alternative Titles
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Practical PCMH
DIY PCMH
“PCMH for the workin’ doc”
PCMH: Yeah, right!
PCMH: All theory, no (green) substance?
PCMH: Why are we still talking about this?
PCMH: Why it (still) matters
Why before How
“He who has a why to live for can
bear almost any how.” -Nietzche
Why PCMH?
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Increasing healthcare costs, percentage of GDP
Poorer health outcomes
Patient lifestyle/low engagement in care
Increasing understanding of the value and ROI
from primary care
• Failure of FFS model (incentivize disease and
intervention over prevention and wellness)
• Burden of chronic disease
• Momentum from big business…
30%
Iceberg
of Additional Costs
to Employers from
Poor Health
Medical Care
Pharmaceutical costs
Workers’ Compensation Costs
70%
Frustration with poor health -both employers and employees
Personal Health Costs
Productivity Costs
Absenteeism
Short-term Disability
Long-term Disability
Presenteeism
Overtime
Turnover
Temporary Staffing
Administrative Costs
Replacement Training
Off-Site Travel for Care
Customer Dissatisfaction
Variable Product Quality
Sources: Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study", JOEM.2009; 51(4):411-428. and
Edington DW, Burton WN. Health and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental
Medicine. 3rd edition. Philadelphia, PA. Lippincott, Williams and Wilkens; 2003: 40-152
Why PCMH is important
for Family Physicians…
• Primary care is receiving a LOT of attention in the
health care debate
• The era of value-based purchasing means there is
a new normal arriving
• Fee For Service with no accountability is
becoming a thing of the past
• Change is coming…change or die!
• You don’t want to be the slowest antelope
• Most Important: it’s the right thing for our
patients!
Leadership is needed: The Four
Camps of Health Organizations
Greater
Resiliency
Lower
Lower
Understanding
Greater
Arkansas is leading!
• Medicaid PCMH
• Comprehensive Primary Care Initiative
• Private Payer Projects (forthcoming)
Leadership:
“Pissing people off at a rate
they can absorb…”
Marci Nielsen, PhD, MPH
CEO, Patient Centered Primary Care Collaborative
“If you always do
what you always did,
you will always get
what you always got.”
- Albert Einstein
Cowboys vs. Pit Crews
Atul Gawande, MD, MPH
• Harvard Professor, Surgeon, Writer
• Public Health Researcher
• Speech at Harvard, 2011
– “We train, hire and pay physicians to be cowboys…”
• The Lone Ranger
– “…Instead, we should be training them to be like Pit
Crews.”
• Focused on teamwork, disciplined, data-driven, standardized
• Also credited with “Triple Aim…Plus One”
Quadruple Aim / Triple Aim + One
Physician
Satisfaction
Reduced
Costs
Patient
Satisfaction
Improved
Outcome
PCMH “Need to Knows”
Dr. Jonathan Sugarman, Qualis Health
AAFP Annual Leadership Focus
May 2, 2014
PCMH “Need to Knows…”
• Despite the short half-life of many health
policy innovations (buzz words), medical
homes continue to capture the attention of
key stakeholders
• PCMH’s are living up to expectations*
• The payment landscape is changing in a
positive way
*Depending on whom you ask!
The Hype Cycle: Waves of Irrational Exuberance
Medical Homes?
Expectations
Real Progress
Plateau of
Productivity
Trigger
Peak of Inflated
Expectations
Trough of
Disillusionment
Slope of
Enlightenment
Time
Adapted from Gartner Research
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Are PCMH’s living up to expectations?
It depends on whom you ask…
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Feb. 25, 2014
"There are folks who believe the medical
home is a proven intervention that doesn't
even need to be tested or refined. Our
findings will hopefully change those views,"
said Mark W. Friedberg, a researcher at
RAND Corp. and lead author of the study,
published Tuesday in the Journal of the
American Medical Association.
(Friedberg et al. JAMA. 2014;311(8):815-825).
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Response to JAMA article
• “A practice could be a PCMH without achieving
certification and achieving certification does not
necessarily mean that a practice is functioning as a
PCMH”
• The study group received financial incentives for NCQA
certification but not for controlling costs
• No after hours or extended hours
• No targeting of high risk populations
• Missing key features: patient-centeredness, teambased care, and behavioral health integration
• Authors response ignored results from bulk of previous
data
States with Medicaid/CHIP Medical
Home Activity Since 2006
States with an Active Role in a
Multi-Payer Medical Home Initiative
Medicaid PCMH
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Minimum 300 ConnectCare Medicaid Patients
Beginners welcome…No certification required
Practice Support: Qualis, AFMC
Must meet milestones, achieve metrics
Reimbursement via Alternative Payment Model:
– PMPM payments (average: $4)
– Continued FFS for encounters as previously
– *Opportunity to participate in “shared savings”
*Must meet eligibility requirements
Regional Family Medicine
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Formerly Kerr Medical Clinic
8 physicians, 3 APNs, 50+ employees,
2 locations
Inpatient / Outpatient / Obstetrics
Lab / Radiology
27,000+ active patient charts
EHR: e-MD’s (April 2012)
MU/PQRS attested
RFM PCMH Journey
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Launched e-MD’s April 2012
Applied CPCi June 30, 2012
Attested Stage I MU mid-July 2012
Formed PCMH Transformation Team
Enrolled Medicaid PCMH
January: first PMPM payment!
Pooled for shared savings with pediatric
practice in Jonesboro
RFM: Existing PCMH Characteristics
• Physician-based teams with “care
coordinator”
• 24/7 live voice access
• Extended office hours: Saturday
• ER, hospitalization avoidance
• Dr. Robert Kerr: “The Answer is ‘Yes’…”
• Initial:
RFM Changes
– Identification of High Risk Patients
– “Care Coordinator”
– Patient notification (text)
– Care Plan (“Well-written SOAP Note”)
– Documentation of same day appt requests
• Upcoming/Ongoing:
– Formal Quality Improvement Process
– Patient Portal
– SHARE
– Formal Policy & Procedures
– Optimizing EMR to perform key PCMH functions
PCMH Challenges
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Organizational structure, inertia, momentum
Culture change (team-based care mind set)
Documentation
Overcoming Lingo/Jargon Gap
Leveraging technology
Doing all of the above in a traditionally highvolume practice (“Just one more thing, Doc…”)
• Payer Issues (comprehensive participation,
data mistrust)
Bottom Line
• PCMH ain’t going away
– FFS as sole means of compensation is (rapidly?)
becoming a thing of the past
– Value-Based Purchasing is becoming the new normal
• Medicaid PCMH: great way to start process
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PMPM’s to assist in beginning processes
Continued FFS for episodic/acute care
Opportunity for shared savings
Practice support from AFMC, Qualis
Prepares your practice for other opportunities, aligns
with other incentives (MU, PQRS, etc.)
Medicaid PCMH Requirements
Dr. Beth Milligan, MD, FAAFP
Arkansas Foundation for Medical Care
Saline Med-Peds
Patient Centered Medical Home
Building a healthier future for all Arkansans
Health
Care
Payment
Improvement
Initiative
Current
state
Future
through PCMH
Triple Aim:
(citizen)
 Does not have a provider
accountable for his care
 Has difficulty navigating the
system
Improve health of population
Enhance patient experience
Reduce or control cost of care
Reinvigorate:
(PCP)
 Lower income than specialist peers
 Not currently using EMR but
considering
 Gets little information from hospitals
and ER’s about patients
Increase PCP’s revenue and takehome pay
Improved practice processes and
workflows
Empowered PCP central to the
management of quality and cost
of care across the health system
Reinvigorate Primary Care
Purpose
Our aim is to create a
Sustainable patient-centered health system
through an evidence-based approach to care delivery
Population-based care delivery system
Episode-based care delivery
Triple Aim Accountability
Improve the health of the population
Enhance patient experience of care
Reduce or control cost of care
Process
Commitment to transform the system
State launches PCMH
Providers enroll
Support for providers
Framework for change
Financial support for care coordination
Technical expertise and vendor support
Transparency into performance
Incentives for quality and cost
Quality metrics ensure provision of appropriate care
Shared savings incentives encourage management of cost of care
Enrollment/Eligibility
PCMH Participation & Eligibility
PCPs enrolled in ConnectCare
Must have at least 300 beneficiaries
Meet participating practice definition (Section 200.000 proposed PCMH manual)
May not participate in the PCCM Shared Savings Pilot
To Enroll:
Provider Portal
www.paymentinitiative.org
Open Enrollment through December 15
January 1 through May 15, 2014
Voluntary
Practice Participation Agreement
Annual re-enrollment
Enrollment/Eligibility
Shared Savings:
Incentive payments made to a shared savings entity for delivery of economic, efficient and quality
care that meets the requirements of Section 232.000
Minimum of 5,000 Medicaid beneficiaries who have been attributed for at
least 6 months
Single practice or by pooling attributed benes across more than one practice
(up to 2 practices per entity 2014)
Practice Support:
Section 241.000 – 242.000
Shared Savings Criteria
First Performance Period
January 1, 2014
Single practice or by pooling attributed benes across more than one practice
(up to 2 practices per entity 2014)
If two practices, they must agree to measure performance together
No default pool
Second Performance Period
Two practice limit for pools is removed
Default pool
Must be part of a shared savings entity to participate in PCMH
Benefits
Providers will receive practice support
Care Coordination
Monthly payments
Technical expertise
Practice Transformation
Option to utilize DMS vendor support
Quarterly performance reports
Shared Savings
Reward high quality care and cost efficiency
Enrollment
Enrollment