February 9, 2010

Patient-Centered Primary Care Model

Steven R. Peskin, MD, MBA, FACP

EVP and Chief Medical Officer,

MediMedia USA

Assistant Clinical Professor, UMDNJ

Presentation Overview

The Need

Key Elements of Patient Centered Medical Home

ACP Medical Home Builder

Demonstration Projects

Discussion

The Need

How do you start to fix the

foundational issue around why

our healthcare system is so

expensive and yet so broken??

0

1000

2000

3000

4000

5000

6000

7000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United States

Germany

Canada

France

Australia

United Kingdom

Average spending on health

per capita ($US PPP)

Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum,

Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?, The

Commonwealth Fund, January 2007, updated with 2007 OECD data

―We do heart surgery more often than anyone, but we

need to, because patients are not given the kind of (1)

coordinated primary care that would prevent chronic

heart disease from becoming acute.‖

George Halverson’s (CEO Kaiser)

Healthcare Reform Now

Need for a New Healthcare Delivery Model

Increasing costs

– Healthcare costs are growing faster than the economy and the

cost of care is becoming difficult for employers, government and

individuals to meet.

Need to improve quality

– Patients receiving recommended treatment 55 % of the time

– Poor U.S. performance on healthcare benchmarks compared to

other developed countries despite spending more.

Regional variation

– Healthcare cost and quality vary substantially among geographic

regions. Little relationship between cost and quality.

Need for a New Healthcare Delivery Model

Inadequate response to chronic care needs

– Increasingly aging and chronically ill population with payment

system that doesn’t recognize services found necessary for

essential care e.g. care coordination, evidence-based population

management, disease self management

Decreased Interest in Primary Care

– The number of new students entering into primary care is

decreasing and physicians who have chosen the field are

disproportionately leaving compared to other specialties.

– Both domestic and international data indicating that higher

proportion of primary care physicians related to higher healthcare

quality and lower costs.

Key Elements of Patient Centered Medical Home

A Joint Proposed SolutionThe Patient-Centered Medical Home (PCMH)

Modern ―medical home‖ concept originally in Pediatric literature in

the 1960’s—a central source of care for ―Special Needs‖ children.

AAFP—Future of Family Medicine Project (2004) ―Personal

Medical Home‖

ACP—Advanced Medical Home (2006)

Key elements of a PCMH are described in a March 2007 joint

statement of principles from ACP, AAFP, AAP and AOA. Often

referred to as the ―Joint Principles‖.

Nexus of patient-centered care, primary care and chronic care

model concepts

The Patient-Centered Medical Home

Redesigns clinical delivery and payment to facilitate– Patient-centered, longitudinal, coordinated care delivered by a

―recognized‖ practice with a personal physician

– Who accepts responsibility for the patient’s ―whole person‖

– Who acts in partnership with patients and in collaboration with multidisciplinary teams (nurses, physician specialists, health educators, pharmacists)

– Who uses practice level systems to improve access and communication, care integration, patient safety and outcomes

– Who accepts accountability for care provided through on-going performance measurement and quality improvement.

A New Model of Care that Redesigns

the Way Primary Care is Delivered and Financed

Patient Personal Physician

Trusted personal physician

Physician who provides, manages and facilitates care

Care is coordinated or integrated across healthcare system

More accessible practice with increased hours and

easier scheduling

Enhanced payment that recognizes the added value of delivering care through the PCMH model

Assistance to practices seeking transformation

Support to practices adopting HIT for QI

Not Defined by any Certain Specialty

Personal PhysicianPatient

Physician as Facilitator, Not a Gatekeeper

Specialist Care Pharmacist Care

Hospital Care

Personal PhysicianPatient

(5) Changes in Clinician Incentives

Fee For Service Fee for service

Prospective payment

Pay for outcomes

Blended PaymentImproved Patient Interaction

Better Work Environment

Team effort

Increased responsibility for admin and clinicians

More time for patients

Better communication and access

Case management

Personal Physician

PPC 1: Access & Communication (9)

PPC 2: Patient Tracking & Registry Functions (21)

PPC 3: Care Management (20)

PPC 4: Patient Self-Management Support (6)

PPC 5: Electronic Prescribing (8)

PPC 6: Test Tracking (13)

PPC 7: Referral Tracking (4)

PPC 8: Performance Reporting & Improvement (15)

PPC 9: Advanced Electronic Communication (4)

TOTAL POINTS: 100

Nine Core Components

Physician Practice Connections – PCMH Levels

Level 1: 25-49 Points; 5/10 Must Pass

Level 2: 50-74 Points; 10/10 Must Pass

Level 3: 75+ Points; 10/10 Must Pass

Media Attention

The resurgence of patient and purchaser interest in primary care is leading to the support of some innovative practice models, largely outside the academic health centers. One is the patient-centered medical home.

– 04/2008

Health policy experts say that unless payment and practice rules are changed, the financial squeeze on primary care doctors threatens to a crisis for patient care.

– 11/7/2007

Primary-care doctors and health system reformers are predicting that a new way of providing health care should provide better, cheaper results.

The idea, called medical homes, combines traditional notions of family physicians with modern technology. It has caught the attention of medical leaders, insurance companies and politicians.

– 3/18/2008

The pay boost rewards doctors who reshape their practices to recreate an era when a trusted family physician helped patients through hospitalizations, coordinated specialist care and provided routine screenings. Such efforts may save money by reducing hospitalizations, ER visits and disease.

– 7/14/2008

The Patient-Centered Primary Care Collaborative

ACP

Providers

333,000 primary care

Purchasers –

Most of the Fortune 500

Payers Patients

AAP

AAFP AOA

ABIM ACC

ACOI

AMA

AHA

IBM General Motors

General Electric FedEx

Microsoft Pfizer

Wal-mart

Business Coalitions

BCBSA

United

Aetna

CIGNA

Humana

WellPoint

HCSC

NCQA AFL-CIO

National Partnership for Women and Families

SEIU

Foundation for Informed Decision Making

Examples of Broad Stakeholder Support & Participation

The

Patient-Centered

Medical Home

80 Million lives

www.acponline.org/medicalhomebuilder

`

Key Characteristics

• National, credible, transparent resource

• Free for physicians and professional associations

• Ability to reach doctors in small and mid-sized practices through their professional associations

• Create a Learning Community for health IT

• Target tools to three groups of healthcare providers

– New adopters

– Current users wanting to transition to a new EHR

– Current users looking to optimize their EHR

Program Features

• AmericanEHRPartners.com - interactive online community

• Educate and enable a wide range of physician needs

– Creation and aggregation of educational materials

– Users can search, display and compare appropriate EHR solutions for their practice, specialty and certification type

– User ratings (i.e. surveys, online ratings) – Verified health professionals

– Automated EHR selection process for RFI submissions & vendor demonstrations

– Podcasts, blogs, newsletters, EHR Readiness Assessments and other interactive tools

– Data dashboards - Professional associations, organizations and physicians

Readiness

Assessment

Comparison Tool

Auto-RFI

Implementation help

Learning network

Podcasts

Blogs/RSS Feeds

Specialty-society

info

Important links

MOCK UP OF

SITE

Demonstration Projects

(Patient Centered Medical Home)

6% decrease in hospital admissions

24 % decrease emergency room

$500, Per member per years savings

Horizon Blue Cross Blue Shield/Partners In Care

For the New Jersey State Health Benefits Program

Results: Clinical Process Metric Improvement

HbA1c Testing

91%

43%0

25

50

75

100

January

2007

November

2007

Permission from Horizon Blue Cross Blue Shield and Partners in Care, Corp.

Lewisburg

Pennsylvania

preTest period

Jan - Oct 2006

First pilot year

Jan – Oct 2007

Percent reduction

Hospital

Admission

365/1000 291/1000 -20%

Hospital

readmissions

15.2% 7.9% -48%

Cost 7% less

9%

4%

22%

13%

0%

5%

10%

15%

20%

25%

Year 1 Year 2 Year 3 Year 4 Year 4.5

Hospitalization E.R. Visit

Marillac’s Integrated Care Patients (PCMH)

Overview of PCMH Commercial Pilot Activity

• 22 projects

• 16 states

• 12 are Multi-stakeholder

• 10 are Insurer-based

Overview of PCMH Commercial Pilot Activity (cont.)

Since October 2008:

• Alabama

• California

• Indiana

• Maryland

• North Carolina

• Oklahoma

• Oregon

• West Virginia

New commercial PCMH projects

under development in at least 8 more

states:

Additionally, new projects are under

development in the previous states,

such as Colorado (Family Medicine

= Identified to have a medical home initiative

Source: National Academy for State Health Policy

State Scan, November 2008

Initiatives to Advance Medical Homes in

Medicaid/ SCHIP

Combined Medical Home Activity

Discussion