Transcript Better Health Technologies Presentation

Patient Centered Medical Home Model:
Overview and Update
July 2008
Vince Kuraitis JD, MBA
Better Health Technologies, LLC
http://e-CareManagement.com blog (208) 395-1197
Jaan Sidorov MD
Sidorov Health Solutions
http://diseasemanagementcareblog.blogspot.com/ (570) 490-6618
“Moving into the next century, the most
important breakthroughs will be in the
from of clinical process innovation rather
than clinical product improvement…the
next big advances in health care will be
the development of protocols for
delivering patient care across health care
settings over time.”
J.D. Kleinke, The Bleeding Edge
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Agenda
I.
What is the “Patient Centered Medical Home
(PCMH)?”
A. Environmental trends
B. History
II.
Recent Developments for the PCMH Model
A. Patient Centered Primary Care Collaborative (PCPCC)
B. Medicare Medical Home Demo (MMHD)
C. AHIP “endorsement” of PCMH
III. Observations/Impressions
A.
B.
C.
D.
Outpouring of support
PCMH coopetition with disease management (DM)
Development speed – two schools of thought
Devil is in the details – many unanswered questions
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I. What is the Patient Centered
Medical Home (PCMH)?
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A) Environmental Trends
• Primary care on the ropes
• Medicare disease management (DM) demos not
living up to expectations
• Doctors are waking up to threats and opportunities
of vendor-owned disease management
• Information & communication technologies enable
new capabilities
• Other trends:
– Quality, patient safety
– Patient centered care
– Wellness, disease prevention
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CMS’ Take on Medicare DM Demos
Linda Magno, CMS, presenting at the Patient Centered Primary
Care Collaborative Summit, November 2007
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B) History of the PCMH
1977
American Academy of Pediatrics (AAP)
establishes policy:
• All information and care for children with
chronic illness should be focused in one
clinical setting
C. Sia, T. F. Tonniges, E. Osterhus, and S. Taba, “History of the Medical Home Concept,”
Pediatrics 113, no. 4, (2004):1473-78.
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History of the PCMH
1997
Wagner et al publish “Collaborative
Management of Chronic Illness”:
• Collaborative provider-patient agreement
on the active problems
• Mutual goal setting
• Self management training with support
• Active and sustained follow-up
M. Von Korff, J. Gruman, S. Schaefer, J. Curry, E.H. Wagner, “Collaborative Management of
Chronic Illness,” Annals of Internal Medicine 127, (1997): 1097-1102
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History of the PCMH
2002
The Chronic Care Model is unveiled:
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Patient Self Management Support
Use of Computerized Systems with Databases
Office Redesign with Teaming
Decision Support
Appropriate Reimbursement
Linkages to Community Resources
T. Bodenheimer, E.H. Wagner, and K. Grumbach, “Improving Primary Care for Patients with Chronic Illness Part 1,” JAMA 288,
no.14, (2002): 1775-1779 and T. Bodenheimer, E.H. Wagner, and K. Grumback, “Improving
Primary Care for Patients with Chronic Illness: The Chronic Care Model Part 2,”
JAMA 288, no. 15, (2002): 1909-1914.
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History of the PCMH
2002
American Academy of Pediatrics coins the
term “Medical Home”:
• “physically and financially accessible,
ensure effective communication and
address children’s educational
developmental and psychosocial needs.”
T. Medical Home Initiatives for Children With Special Needs Project Advisory
Committee,
American Academy of Pediatrics, “Policy Statement. The Medical Home,”
Pediatrics 2002 110, no. 1, (2002): 184-186.
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History of the PCMH
2004
Future of Family Medicine Project is
launched by 7 primary care organizations:
adopts the “medical home” and the
“chronic care model.”
Future of Family Medicine Project Leadership Committee, “The Future of Family
Medicine: A Collaborative Project of the Family Medicine Community,”
Ann Fam Med 2, (2004):s3-s32
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History of the
PCMH
2006-2007
American College of Physicians, followed by AAFP,
AAP and AOA endorse the “Patient Centered
Medical Home”
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2)
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quality and safety with evidence-based practice and patient participation in
decision making,
care coordination and integration thanks to information technology support,
registries and health information exchanges as well as inclusion of the health care
system and community,
physician directed medical practice with teaming and delegation of responsibilities,
appropriate payment,
the provision of relationship with a personal physician,
enhanced access with expanded hours, open scheduling and remote
communication
the expansion of the MH model in a whole person orientation that includes not only
chronic illness but prevention, acute or episodic illness and end of life care.
American College of Physicians, “The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health
Care. Policy Monograph of the American College of Physicians,” 22 January 2006,
http://www.hhs.gov/healthit/ahic/materials/meeting03/cc/AC
P_Initiative.pdf and American Academy of Family Physicians, American Academy of Pediatrics, American College of
Physicians, American Osteopathic Assocation, "Joint Principles of the Patient Centered
Medical Home,” March 2007, www.medicalhomeinfo.org/Joint%20Statement.pdf
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History of the PCMH
2007-2008
• American Academy of Family Practice
launches “TransforMED,” piloting
versions of PCMH nationwide
• Other Managed Care Organizations create
pilots based on CCM/PCMH
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II. Recent Developments for
the PCMH Model
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A) Patient Centered Primary Care
Collaborative (PCPCC)
2007-2008
Coalition of employers, payers, physician groups,
and others joined to develop and advance the
PCMH:
• 180+ members
• 4 collaborative centers
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Promote Public Payer Implementation
Multi-Stake Holder Demonstration
Health Benefit Redesign and Implementation
eHealth Information Exchange and Adoption
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IBM Healthcare and Life Sciences
PCMH Pilots Map
Note: this chart is from Carol Flamm, who leads the PCPCC Center for
Multistakeholder Demonstrations. It doesn’t bear any one-to-one
relationship to the PCMH pilot details, but is offered as an example of how
the state and local activities might be summarized.
RI
Multi-Payer pilot
discussions/activity
Identified pilot activity
No identified pilot activity
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© 2007 IBM Corporation
B) What is the Status of the Medicare
Medical Home Demo (MMHD)?
December 2006 – Congress passes the MMHD
• Patient population: not clear
– MMHD legislation: “high-need populations,” defined as
“individuals with multiple chronic illnesses that require regular
medical monitoring, advising, or treatment.”
– The AMA/Specialty Society Relative Value Scale Update
Committee (RUC) methodology has reinterpreted this as 87%
of Medicare patients
– Clarification will come in the CMS Request for Proposals
• MMHD is different from Medicare Health Support (MHS)
– No requirement of 5% guaranteed savings
– Physicians can keep 80% of savings
• CMS MMHD website now says the project will begin early in
2010!
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What’s the Right Payment Level for the
PCMH?
• Very Low -- $3 PPPM, e.g., Community Care of North Carolina
• Low -- $30 to 50 PPPM, e.g., RUC
• Medium -- $75 to 150 PPPM
– Medicare Health Support
– Deloitte Consulting model
• High -- $300+ PPPM, e.g., case management payments for
complex patients
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AMA/RUC Recommendations for
PCMH Care Coordination Fees
In April 2008, the American Medical Association/Specialty Society
RVS Update Committee (RUC) made recommendations for PCMH
care coordination fees
• Physician panel size = 250
• Three tiered system based on capabilities of physician office
– Tier 1: Entry level
– Tier 2: Typical
– Tier 3: Optimal
• Tiers are not based on severity of patients
• Proposed physician time and work RVUs for each tier
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Estimated RUC Recommended PPPM
Payments
• Tier 1: $30
• Tier 2: $40
• Tier 3: $50
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Medicare Improvements for Patients and Providers
Act of 2008 (HR 6331, Section 133)
Passed July 14
Expansion:
• The Secretary may expand the duration and the
scope of the [MMHD] ... if the Secretary determines
that such expansion will result in any of the following
conditions being met:
(A) The expansion of the project is expected to improve the
quality of patient care without increasing spending under the
Medicare program...
(B) The expansion of the project is expected to reduce
spending under the Medicare program....
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C) AHIP “Endorsement” of the PCMH
Raises More Questions
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III. Observations/Impressions
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A) Outpouring of Support
• Paul Grundy, IBM: “If that executive had a
“medical home,” a primary care doctor providing
comprehensive, holistic care, the cause of his
pain may have been identified much earlier.”
• Senator Durbin (D-IL.): “The Medical Home model
can reduce costs and improve quality of
healthcare services for every person in America.”
• Karen Davis (Commonwealth Fund) : “Medical
home could make an enormous difference ins
address health disparities”
• Herb Kuhn (CMS): “The medical home is one of
the things that can be helpful”
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B) DM-PCMH Coopetition
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Disease Management
Population focused
Disease managers
Remote patient activation
Change patients &
physicians
Access to capital
**P4Participation**
**Insurance risk/savings**
Market
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PCMH
Office practice focused
Multidisciplinary teams
Local patient activation
Change physicians &
patients
Poor access to capital
Use P4P to underwrite?
Revenue
Policy
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How Do DM and MD Skills Overlap?
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Continuous quality improvement
Epidemiology
Social psychology, adult learning
Patient-centered interviewing
Large dataset management with
advanced analytics
Stages of change management
Motivational interviewing
Clinical process improvement
Community resource integration
Building self-efficacy, activation
Sustaining behavior change
Field-based care teams
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Predictive modeling
Disease registries
Interoperable EHRs/PHRs
Remote biometric monitoring
Consumer-oriented education,
motivation
Behavioral incentives
Scalable platforms for inbound
and outbound patient contact
Low health literacy counseling
Culturally-sensitive health
education materials
Overcoming resistance to
change
Gordon Norman MD, MBA; Alere. Presented at Healthcare
Unbound conference, July 2008
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C) Development Speed – Two Schools
of Thought
Implementers
• Opportunistic/
Interventions evolve
• “Real life”
experiments
• Answers today
• “Experiential”
learning
Researchers
• Identify the optimal
approach
• Randomized
controlled trials
• Willing to wait
• Single answer/
Triangulation
Bruce Landon MD, MBA; Harvard Medical School.
Presented at PCPCC meeting, July 2008.
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D) Devil is in the Details – Many
Unanswered Questions
• How will a MH be defined, recognized (e.g., see next slide),
and measured?
• What should payment levels be for the MH?
• Will physicians invest time and $$ to participate?
• Will physicians change behavior and workflow?
• Will physicians want to collaborate with payers?
• Is the PCMH scalable across physician networks?
• Does the PCMH reduce claims expense? So far the answer
is ‘we don’t know.’
• Will the Medicare Medical Home Demo be successful?
• Will other pilot projects prove successful?
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NCQA, January 2008
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“Providers of care should find it unethical
and even immoral to continue to provide
episodic, uncoordinated care.”
Don Klitgaard, MD, FAAFP; presented to the PCPCC; July 16,
2008
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END
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APPENDIX
Joint Principles of the PCMH
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Joint Principles of the PCMH

American Academy of Family Physicians (AAFP)
American Academy of Pediatrics (AAP)
American College of Physicians (ACP)
American Osteopathic Association (AOA)
February 2007
“An approach to providing comprehensive primary care for children, youth and
adults. The PC-MH is a health care setting that facilitates partnerships between
individual patients, and their personal physicians, and when appropriate, the patient’s
family.

Principles:

1) Personal physician - ongoing relationship with a personal physician with first
contact, continuous and comprehensive care.

2) Physician directed medical practice – team of individuals who collectively
take responsibility for the ongoing care of patients.

3) Whole person orientation – arranges all care needs or taking responsibility
for appropriately arranging care, including acute care; chronic care; preventive
services; and end of life care.

4) Care is coordinated and/or integrated across all elements of the complex
health care system and community Care is facilitated by registries, information
technology, health information exchange.

5) Quality and safety:
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Practices advocate for their patients to support the attainment of optimal, patientcentered outcomes
Evidence-based medicine and clinical decision-support tools guide decision making
Physicians in the practice accept accountability for continuous quality improvement
Patients actively participate in decision-making
Information technology is utilized
Practices go through a voluntary recognition process b
Patients and families participate in quality improvement activities at the practice level.

6) Enhanced access to care is available through systems such as open
scheduling, expanded hours and new options for communication between
patients, their personal physician, and practice staff.

7) Payment appropriately recognizes the added value
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reflect the value of physician and non-physician staff
pay for services associated with coordination of care
support adoption and use of health information technology
support provision of enhanced communication access
recognize the value of physician work associated with remote monitoring
allows for separate fee-for-service payments for face-to-face visits.
recognize case mix differences in the patient population being treated within the
practice.
allow physicians to share in savings from reduced hospitalizations associated with
physician-guided care management in the office setting.
allow for additional payments for achieving measurable and continuous quality
improvements.
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APPENDIX
Better Health Technologies, LLC
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Better Health Technologies, LLC
• Technology and health care delivery are shifting:
– From: Acute and episodic care delivered in hospitals and
doctors’ offices
– To: Chronic disease and condition management delivered in
homes, workplaces, and communities
• BHT provides consulting, business development, and
speaking services to assist companies in:
1) Understanding the shift
2) Positioning – what’s the right strategy, tactics, and
business model?
3) Integrating your offering into the value chain – what are
the right partnerships?
• Blog: http://e-CareManagement.com
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Centocor
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