After the ACA: Designing health systems with PCMHs, ACOs and
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Transcript After the ACA: Designing health systems with PCMHs, ACOs and
After the ACA:
Designing health systems with PCMHs, ACOs and PCTs
Nate Kittle, MS4
Robert Graham Center Visiting Scholar
October 2012
Overview
Background Information
Research Question
Patient Centered Medical Home (PCMH)
Integrated Systems
Accountable Care Organizations – ACOs
Primary Care Trusts (PCTs)
Putting it all together
Conclusions
Background Information
Patient Protection and Affordable Care Act
Signed into law March 23, 2010.
Major aim to decrease the number of uninsured Americans
Mandates
Subsidies
Tax Credits
Upheld by SCOTUS on June 28, 2012.
http://unlikelyvoter.com/2010/03/25/four-polls-on-the-ppaca-democratsstart-out-behind/
PPACA
Implications of PPACA
January 1, 2014 = 14 million U.S. residents newly insured!
By 2021 = Extra 16 million U.S. residents insured
Grand total = approximately 30 MILLION NEWLY INSURED
lonelyplanetimages.wordpress.com
Who are the 30 Million?
Race
White
Black
Native
American/Pacific
Islander
Asian
Multiracial
Marital status
Married
Single
Language
English
Spanish
Other language
Unknown
Newly
insured
75%
16%
Currently
insured
79%
13%
2%
1%
5%
2%
5%
2%
32%
52%
40%
29%
69%
24%
5%
1%
88%
7%
4%
1%
Who are the 30 Million?
Not in labor force
Newly
insured
27%
Currently
insured
24%
Employed, full time
42%
59%
Employed, part time
17%
15%
12%
15%
Employment status
Unemployed
Education
High school degree or
61%
less
Some college (no
17%
degree)
Associate’s degree
8%
35%
18%
11%
Bachelor’s degree
11%
24%
Graduate degree
3%
13%
Who are the 30 Million?
Excellent
Newly
insured
26%
Currently
insured
37%
Very good
29%
33%
Good
33%
21%
Fair
9%
6%
Poor
3%
2%
Health status
Compared with the current insured population these patients
will be poorer, older, less likely to have full-time employment, less
likely to have a college degree and more likely to speak a language
other than English. Only a quarter will have previously had health
insurance..
The Impact of 30 million
The Massachusetts example
Access and Use of health care improved
More adults reported visits to doctors and fewer adults reporting going
without needed health care.
Evidence of strong gains in Preventive care
Challenges
Provider Capacity
“Constraints on provider supply…have ben exacerbated”
Nearly 15% of adults visited the ED for non-emergency conditions
o 75% because they needed care after hours
o 50% reported not getting an appointment soon enough
Research Question
What evidence exists for health system reform that may
be able to help curb the possible negative impact of an
extra 30 million insured patients and achieve the Triple
Aim of reform – Better care for individuals; Better health
for the community; and Reduction in the cost of care.
PCMH
Integrated Systems (ACOs)
Primary Care Trusts
Patient Centered Medical Home
Brief History
1967: American Academy of Pediatrics introduced the “medical
home”
2002: The Future of Family Medicine
Every American should have a Personal Medical Home
2007: Joint principles of the Patient Centered Medical Home
American Academy of Family Physicians
American Academy of Pediatrics
American College of Physicians
American Osteopathic Association
PCMH: Joint Principles
Personal Physician
Physician Directed Medical
Practice
Whole Person Orientation
Coordinate/Integrated
Care
Quality & Safety
Enhanced Access
Payment Reform
http://thepcmh.org/
PCMH: Realizing the Principles
Robust investment in Health Information Technology
eVisits, eCommunitcation, Personal Health Portals, etc.
Provider payment reform
Focused on patient outcomes and health system efficiencies
Team-based education and training of health professionals
Team of Physician, Case manager, Mental health professional,
Nursing, Patient educator, etc.
http://www.google.com/imgres?um=1&hl=en&rls=com.microsoft:enUS&biw=1024&bih=603&tbm=isch&tbnid=r3-UkndfnFTR5M:&imgrefurl=http://www.aroragroup.biz/&
PCMH: Outcomes
ED Visits
Hospital Admissions
Hospital Length of Stay
Hospital Re-Admissions
Total Costs
Specific Disease Outcomes
http://ondemanddentist.com/268/why-you-should-notgo-to-the-er-for-a-toothache/
PCMH: Outcomes – ED Visits
Initiative
Results
Years of Review
Air Force
14% fewer ED/Urgent care
visits
2009-2011
Florida: Capital Health Plan
37% Lower ED visits
2003-2011
North Carolina:
Community Care
23% lower ED utilization
and costs
2003-2010
Ohio:
34% decrease in ER visits
2008-2010
29% Fewer ED visits
2006-2008
Humana Queen City Physicians
Washington:
Group Health of Washington
PCMH: Outcomes – Hospital Admissions
Initiative
Results
Years of Review
Veterans Health
Administration
27% lower hospitalizations
2007-2009
Pennsylvania:
Geisinger Health PCMH
25% lower hospital
admissions
2005-2010
North Dakota:
BCBS of North Dakota
18% lower inpatient
hospital admission rates
compared to general N.D.
population
2005-2006
Minnesota: HealthPartners
24% fewer hospital
admissions
2004-2009
Alaska: Alaska Native
Medical Center
53% reduction in hospital
admissions
10-year span (not specified)
PCMH: Outcomes – Length of Stay
Initiative
Results
Years of Review
California:
BCBS of California
50% fewer inpatient
stays of 20 days or more
2010
Florida:
Capital Health Plan
40% lower inpatient
hospital days
2003-2011
Minnesota: HealthPartners
30% lower length of stay
2004-2009
Pennsylvania:
Geisinger Health
Reduced hospital length
of stay by half a day
2005-2010
PCMH: Outcomes – Re-Admissions
Initiative
Results
Years of Review
Michigan:
BCBS of Michigan
6% lower 30-day
readmission rates
Minnesota: HealthPartners
40% lower re-admissions
2004-2009
New Jersey:
BCBS of New Jersey
25% fewer hospital
readmissions
2011
Pennsylvania:
Geisinger Health
50% lower readmissions
following discharge
2005-2010
Texas: BCBS of Texas
23% lower readmission
rates
2009
PCMH: Outcomes – Total Costs
Initiative
Results
Years of Review
North Carolina:
Community Care
$60 million in 2003
$161 million in 2006
$103 million in 2007
$204 million in 2008
$295 million in 2009
$382 million 2010
2003-2010
Minnesota: HealthPartners
Overall costs decreased
to 92% of state average
in 2008
2004-2009
Maryland: CareFirst BCBS
Nearly $40 million savings
in 2011
2011
Florida:
Capital Health Plan
18% lower health care
claims costs
2003-2011
Oregon: CareOregon
Medicaid and Dual Eligibles
9% lower PMPM costs
2007-2009
PCMH: Outcomes – Specific Diseases
Initiative
Results
Years of Review
Pennsylvania:
Geisinger Health
Improved quality of care:
• 74% for preventive care
• 22% for coronary artery
care
• 34.5% for diabetes care
2005-2010
Washington:
Regence Blue Shield
14.8% improved patient
reported physical function
and mental function
65% reduced patient
reported missed workdays
2007-2009
Ohio: Humana Queen City
22% decrease in patients
with uncontrolled blood
pressure
2008-2010
Air Force
77% of diabetic patients
2009-2011
had improved glycemic
control at Hill Air Force Base
PCMH: Criticisms
Variation among programs
Scalability
Infrastructure, care teams, etc.
Large start-up costs
Lack of long-term results
PCMH: Criticisms
PCMH: Bottom-line
There are obvious benefits to the PCMH
model but the extreme variability and large
start-up costs cause some
states/organizations to hesitate in its
implementation.
Is this more than a fad?
Integrated Systems
Definitions:
Integration is a set of methods/models on the funding,
administrative, organizational, service delivery and clinical
levels designed to create connectivity alignment and
collaboration between the cure and care sectors.
The goal: enhance quality of care, consumer satisfaction and
system efficiency
greenologic.co.uk
Integrated Systems - Kaiser
Poster Child for Integration
Founded in 1945
Largest non-profit integrated system in the US
Consist of Kaiser Foundation Health Plans and Permanente
Medical Groups
The medical groups are physician owned and function to provide services
for health plan members
worldchiropracticalliance.org
Integrated Systems - Kaiser
Principles
Information Continuity – KP HealthConnect
Care Coordination and Transitions
Valued role of Primary Care
Peer Review and Teamwork
Easy Access to Appropriate Care
Patient-centered
Multiple “entry points”
http://67.159.41.164/kp-health-connect.html
Integrated Systems - Kaiser
Outcomes
Improving Transitional Care:
Annual cost savings of $4 million from decreased readmissions (2.4% of
intervention patients vs 14% usual-care) and ED visits (7%-16%
respectively). Satisfaction in the program exceeds 90% of physicians and
95% patients
With the use of multiple “entry points”
Northern California members use of ED declined by 1/3 over the course
of 11 years, from rate of 300/1000 adults in 97 to 205/1000 in 08.
Integrated Systems - Kaiser
Bottom Line
Rich history of integration that has clearly led to great patient
outcomes, patient satisfaction, physician satisfaction and cost
reduction.
However, much like PCMH project there needs to be a huge
investment in health IT, you need strong leaders to create a
culture of excellence.
Integrated Systems – ACO
CMS defines ACO:
“an organization of health care providers that agrees to
be accountable for the quality, cost and overall care of
Medicare beneficiaries who are enrolled in the
traditional fee-for-service program who are assigned
to the organization.”
Advocates of this system believe that it will strengthen
the US health care by improving care, controlling
costs, & by holding physicians accountable for results.
Integrated Systems - ACO
Challenges to Implementing in the US
Dominance of solo/small-group independent
physician practices
Voluntary medical staff structure within most hospitals
Fails to engage physicians in leading the system changes
needed to deliver consistently safe, cost-effective and highquality care
Dominance of FFS reimbursement
Integrated Systems - ACO
Medicare’s Physician Group Practice Demonstration
2000 – Congress asked DHHS to test incentive-based payment
methods for physicians which would aim to encourage care
coordination and an investment in more efficient service
delivery methods.
CMS contracted with 10 large multispecialty groups with
diverse organizational structures, including free-standing
physician groups, academic faculty practices, integrated delivery
systems and a network of small physician practices.
Goal is to generate cost savings by reducing avoidable hospital
admissions, readmissions and ED visits while improving quality.
Integrated Systems - ACO
PGP Demonstration
Shared Savings:
Received regular Medicare FFS payments
Also eligible for an 80% share of Medicare’s savings in practitioners
collectively achieved specified quality and cost targets
policymed.com
Integrated Systems - ACO
PGP Demonstration Results:
Mixed at best
Quality of Care was improved, but little savings were seen
Integrated Systems - ACO
Bottom Line:
There is some reason to be concerned. The results were less
then perfect and some analysts believe there may not be enough
of an incentive for organizations to restructure in order to
qualify for ACO Shared Savings.
There will need to be large investments on health IT, etc. to see
the savings necessary to share in the savings. This may be very
difficult for your average health care system.
Integrated Systems – Other Examples
Advocate
Physician – Hospital partnership
Pay for performance: 10% of allowable billing and based on specialty
specific metrics.
Patient outreach, reduced hospital LOS, reduced ED use, etc
In 2010 the partnership distributed $38 million in incentive payments to
3700 physicians.
Group Health
Consumer-governed health plan
Pre-paid group practice that integrates care and coverage.
Salaried physicians – no fee-for-service pressures
Providers, clinics, hospitals and insurance plans under the same
organization
Able to make long-term investments in members’ health and manages
resources to get best quality and value.
Integrated Systems – Other Examples
Geisinger
Large integrated system in Pennsylvania that offers incentives to
its physicians to improve patient outcomes an cut costs. (20%
total salary)
Specialists: Quality (40%) Innovation (10%) Legacy (10%), Growth
(15%) and Financial (25%).
Primary Care: 60% quality measures
Physicians who receive incentives to achieve all diabetes targets
have better clinical outcomes for MIs, Strokes, retinopathy, and
amputations than patients who receive their care from other
physicians.
Integrated Systems
Bottom Line:
Mission to manage the full continuum of care and be
accountable for the overall costs and quality. Can take several
forms: large integrated systems (Kaiser) and Physician-hospital
partnerships (Advocate).
Performance measurement to evaluate the quality of care and to
prevent potential overuse (FFS) and underuse (Capitation) is a
cornerstone of this model.
More fully integrated ACOs provide higher quality, more
efficient care than smaller more loosely organized ones.
Kaiser vs Advocate
Primary Care Trusts
Brief History
2000 Launch and
2cuk.co.uk
303 originally established to:
Purchase care for local communities from hospitals and other local
providers
Directly provide services such as community care
Work with local agencies to tackle health inequalities/improve public
health
2002 role expansion
Improve health of the community
Secure the provision of high-quality services
Integrate health and social care locally
2005 – reduced to 152 to match local authorities and strengthen
commissioning
2010 – Role had expanded to more than 60 separate duties
Primary Care Trusts - Outcomes
ED Admissions
Increased by 11.8% from 2004-05 to 2008-09.
1.35 million extra
Wide variety when Trusts are compared
Some saw increases while others saw decreases
Hypothesize that increase is due to fragmentation of care
ukemergency.co.uk
Primary Care Trusts - Outcomes
Deficit vs Surplus PCTs
Deficit: In rural areas – 7 times lower population density
Surplus: In more socially deprived areas, staff more stressed
Need to adjust metrics when looking at rural and urban centers to
disperse funds in a more equitable manner.
Infant and Perinatal Mortality
70-80% of PCT variability in infant and perinatal mortality can be
explained by combination of deprivation, ethnicity and maternal age
Differences in PCT spending do not reliably explain differences in
rates of infant and perinatal mortality seen across the country.
Primary Care Trusts - Criticism
Lack of health IT infrastructure to integrate care
Lack of strong leadership
Department of Health priorities limited scope of PCT
effectiveness on local level
Extreme variability seen between PCTs
alwpctpublichealth.co.uk
Primary Care Trusts – Bottom Line
Idea to de-centralize commissioning was good in theory but
didn’t necessarily play out over the course of the past decade.
Too many central NHS priorities got in the way of effective
PCT response to local needs
Lack of effective leaders trained in commissioning slowed the
process and made for an impatient public
2013 England abolishing PCTs and are headed to new model
where GP-led organizations commission services.
Taking It a Step Further
The Medical Neighborhood
PCMH + Integrated Care System
Regardless of the organizational structure, an ACO will not succeed
without a strong foundation of high-performing primary care
Medical home care coordination and care management activities will
enable the ACO to realize cost savings. PCMHs can benefit from ACO
infrastructure and support to help PCMHs meet their functional
requirements
PCMH is the centerpiece of the medical neighborhood and needs to be
nested within a well-functioning medical neighborhood (ACO) that
ensures everything that needs to happen does indeed happen.
pcpcc.net
The Rhode Island Experiment
The Medical Neighborhood + PCTs = The Medical
City/County/Township?
Foundation of primary care (PCMH)
Integration across all levels of care (primary and secondary)
Responsive to the local environment by commissioning local
services
Spain: 2 decades of reform
Spain ranked 6th among 30 OECD democracies in life expectancy.
Infant mortality in 09 was among the lowest in the world
Reduction in the premature deaths from specific conditions:
Circulatory 322.1 to 159.0/100k population
DM 19.8 to 12.5/100k population.
All Models Effect on ED Visits
Model
Change in ED Visits
PCMH (Average of the 5
stated earlier)
Kaiser
27.4% decrease
PCT
50% decrease (300/1000 to
150/1000)
11.8% increase
Conclusions
There will be 30 million newly insured citizens by 2021
Need for primary care is well documented
Continue PCMH programs and report results
Attempt to identify what REALLY works – decrease variability
Care integration can increase quality, but does it decrease
costs?
Health IT, Strong physician leadership
Lessons from across the pond
Leadership, only try once, primary care investment works
Thank-you!
Questions/Comments/Future Actions
References (not in Annotated Bibliography)
“Health Insurance Exchanges: Long on options, short on time,” PwC, Oct. 2, (pwc.com/us/en/healthindustries/publications/public-private-health-industry-exchange-models.jhtml)
Long, Sharon “What Is the Evidence on Health Reform in Massachusetts and How Might the Lessons from
Massachusetts Apply to National Health Reform?” Urban Institute Report. June 2010.
“The Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change”
Robert Graham Center Report. November 2007.