Transcript The Medical Home in Pediatric Practice

Jim Stout, MD, MPH
Professor of Pediatrics
University of Washington
A. Chris Olson, MD, MHPA
President
Washington Chapter of the AAP
Clinical Professor
University of Washington
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Value of Primary Care
Medical Home Model
Care Coordination
Family-Centered Care
Quality Improvement
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Undervaluing E&M Codes predominately
provided by PCP’S
RVU’s determinations that overvalue some
services/procedures to the detriment of other
services in Medicare’s budget neutral system
Not paying for those services required to
allow the PCP to provide patient-focused,
longitudinal, coordinated care.
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Cuts to reimbursement that
disproportionately adversely impact primary
care physicians
Providing incentives for volume of services
with no regard to the quality or efficiency of
the clinical service provided
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“The collapse of primary care will result in our
health care system becoming increasingly
fragmented, over-specialized, and inefficient
– and lead to poorer quality, higher costs,
reduced access, and increased patient
dissatisfaction.” Reform of the Dysfunctional Healthcare
Payment and Delivery System American College of Physicians, A position
paper. 2006
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States with higher ratios of primary care to
specialty care have better health outcomes.
Areas with more specialists have higher per
captia Medicare spending
Increase in primary care physicians is
associated with a significant increase in
quality of health services, as well as a
reduction in costs.
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Cross national comparisons indicate that
nations with stronger primary care
infrastructures have lower rates of premature
births, deaths form treatable conditions, and
post neonatal mortality.
Studies have repeatedly demonstrated that
the vast majority of Americans prefer a
sustained relationship with a primary care
provider.
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Primary care oriented countries achieve
notably better outcomes for health in early
childhood: low birth weight rations,
postneonatal mortality, infant mortality, and
child mortality, including deaths from injury.
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The American Academy of Family Physicians
believes that everyone should have a personal
medical home that serves as the focal point
through which all individuals-regardless of age,
sex, race, or socioeconomic status-receive acute,
chronic, and preventive medical services. Through
an on-going relationship with a family physician in
their medical home, patients can be assured of care
that is not only accessible but also accountable,
comprehensive, integrated, patient-centered, safe,
scientifically valid, and satisfying to both patients
and their physicians. (May Board 2006)
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“Attributes of the advanced medical home
include promotion of continuous healing
relationships through delivery of care in a
variety of care settings according to the
needs of the patient and skills of the
medical provider. Physicians are once again
partners in coordinating and facilitating
care to help patients navigate the complex
and often confusing health care system by
providing guidance, insight and advice in
language that is informative and specific to
patients’ needs.”
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Increased patient and family satisfaction
Establishment of a forum for problem solving
Improved coordination of care
Enhanced efficiency for children, youth, and families
Efficient use of limited resources
Increased professional satisfaction
Increased wellness resulting from comprehensive care
Provide a basis for quality improvement in the care of
children and families
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What is a Medical Home?
NOT just a building or place but a way of providing
health care services that are:
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Accessible
Family-centered
Coordinated
Comprehensive
Continuous
Compassionate
Culturally Sensitive
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Personal physician vs. team of providers
Care Coordination
Quality and Safety
◦ “Physician in the practice accept accountability for
continuous quality improvement through voluntary
engagement in performance measurement and
improvement”
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Payment Discussion
◦ Recognizes the added value provided to patients
who have a patient-center medical home.
◦ Recognize case mix differences in the patient
population
◦ Separate fee-for-service payments for face to face
and other management services ie. Care
coordination
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Primary care is on the verge of collapse
Very few young physician are going into primary care (EROAD)
There will not be enough primary care physicians to take care
of an aging population with growing incidences of chronic
diseases
Without primary care, the health care system will become
increasingly fragmented, over specialized, and inefficient.
Leading to poorer quality care at higher costs
When compared with other developed countries, the United
States ranked lowest in its primary care functions and lowest
in health care outcomes, yet highest in health care spending.
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The Secretary shall establish a medical home demonstration
project to redesign the health care delivery system to provide
targeted, accessible, continuous and coordinated, familycentered care to high-need populations and –
◦ Care management fees are paid to personal physicians
◦ Incentive payments are paid to physicians participating in
practices that provide a medical home
“High-need population” means individuals with
multiple chronic illnesses
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Medical Home Demonstration project tied to
SCHIP reauthorization
Demonstration Project Aims
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Increase cost efficiency
Increase access to appropriate services
Increase patient satisfaction
Decrease inappropriate ED utilization
Decrease service duplication
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Provide appropriate preventive care
Provide appropriate referrals to
multidisciplinary services
Increase school attendance
Increase agreed upon measures of quality
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Implementation phase
Practice Change Principles
Family involvement in practice change
Increases interest in practice
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Changing a pediatric
practice is like trying to
change the tire on a
bicycle while you are
riding it
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Implementation phase
Practice Change Principles
Family involvement in practice change
Increases interest in practice
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Knowledge
Persuasion
Decision
Implementation
Confirmation
Innovators
Early
Adopters
2%
13%
Early
Majority
35%
Late
Majority
Traditionalists
35%
15%
Source: Based on Ryan and Gross (1943).
Year
1941
1940
1939
1938
1937
1936
1935
200
1934
250
1933
1932
1931
1930
1929
1928
1927
Number of Farmers in Communities
300
Cumulative Number
of Adopters
150
100
50
0
Expert
Planning
Group
Meeting
Participants
Prework
P
D
A
Change
Concepts
Refine
Collaborative
Design
P
S
D
A
Action
Period 2
LS2
(Oct)
Supports
E-mail Visits
Phone Documents
Assessments
Institute for Healthcare Improvement
LS 3
(March)
We are
here
D
A
S
Action
Period 1
LS 1
P
S
Action
Period 3
Closeout
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Union Avenue Pediatrics/ Neurobehavioral
Assoc.
Swedish Children's Clinic
Ida Karlin Pediatrics
Virginia Mason Sand Point Pediatrics
SW Washington Medical Center (Vancouver)
Healthy Steps
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International Community Health Services
Swedish Children's Clinic
Ida Karlin Pediatrics
Columbia Basin Health Assoc.
Polyclinic Pediatrics
Group Health - Tacoma South Pediatrics
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Valley Family Medicine
Skagit Pediatrics
CMCC/Mary Bridge Children's Health Center
Odessa Brown Children's Clinic
Eastgate Public Health Center
Northwest Pediatric Center, Inc.
Virginia Mason Sand Point Pediatrics
Polyclinic Pediatrics
Expert
Planning
Group
Meeting
Participants
Prework
P
D
A
Change
Concepts
Refine
Collaborative
Design
We are
here
P
S
D
A
Action
Period 2
LS2
(Oct)
Supports
E-mail Visits
Phone Documents
Assessments
Institute for Healthcare Improvement
D
A
S
Action
Period 1
LS 1
P
LS 3
(March)
S
Action
Period 3
Closeout
“Impedimento non mi piega”
Leonardo daVinci
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Raises eligibility to 250% of poverty (Family of
four $50,000) and in 2009 to 300% poverty
Funding for outreach
Increase reimbursement to providers
Quality measures
◦ “Shall identify explicit performance measures that
indicate that a child has an established and
effective medical home”
◦ Such as
 Vaccine rates
 Well child care utilization
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Care management of children with chronic
illnesses
Emergency room utilization
Preventive oral health service utilization
Report by December 2007
Reimbursement in 2009 related to
measurements of quality
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Value of medical home concept in developing case for
primary care
◦ Ability to frame the issue of increasing access to a medical
home is good for the state and the families
◦ Financial realities of the small businesses that provide the
medical home for families
◦ Great to have insurance but if no provider can afford to see
patients, insurance alone won’t solve the problem.
Governor’s agenda
Legislative agenda
Relationships
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What has been your experience in promoting
medical home?
What tools do you need to implement medical
home in your practice, your community of
physicians?
What are your barriers to implementation and
quality measures?
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