Reinventing Medicaid findings are Outstanding Oklahoma's patient-centered medical home initiative

has reduced Medicaid costs $29 per patient per year from 2008 to 2010. Moreover, use of evidence-based primary care, including screening for breast and cervical cancer, increased.

The Colorado initiative expanded access to care. Before the initiative, only 20 percent of pediatricians in the state accepted Medicaid; as of 2010, 96 percent and did and at a lower cost to the state.

Vermont, inpatient care use and related per-person per-month costs decreased 21 percent and 22 percent, respectively, from July 2008 to October 2010. ER use and related per-person per-month costs decreased 31 percent and 36 percent, respectively. 

Patient Centered Medical Home in Washington in State Acute care spending there was 18 percent below the national average. Inpatient stays per beneficiary were 35 percent below the national average.

Citation -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results," Health Affairs, July 2011 30(7):1325–34.

The Bottom Line in Medicaid PCMH starting to show an impact in access to care, quality, and cost control .

Out in July 2011

BCBS MA 6% decrees cost (NEJM) BCBS Mi 2670 physician (BIG study)

2010 2011

Adults (18-64)

ER visits -6.6% -9.9%Primary care sensitive ER Visits -7.0% -11.4%Ambulatory care sensitive Hospitalizations (per 1,000) -11.1% -22.0%

MGMA: 70% of Practices at Least Interested in Becoming Patient Centered Medical Homes

13 to 20 % are already on the road Some states Michigan, Minnesota, Maryland,

RI, VT 50% already are well on the road !! Standard of care in the VA, DOD IBM $ 60 per Member BCBS HI 14.6% ^

Outside Hospital video clip

Who was the Shooter’s Doctor?

Population managementAccountability

$10,743

$28,530

+166%

Why Innovate Affordability

Costs continue their upward climb…

…with employers still picking up much of the tab…

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

a- Employer Cost - Employee Payroll Contributions - Employee Out of Pocket Expenses

2001 2009 2019

$4,918

+118%

The Elephant in the room

Health care is a business issue, not a benefits issue

The Cause? Mostly due to unregulated fee-for-service payments and an over reliance on rescue/specialty care. This is stark evidence that the U.S. health care Industry has been failing us for years “Commonly cited causes for the nation's poor performance are not to blame - it is the failure of the deliver system!!”

You the AHC’s - Unaccountable Care Organizations PART of this problem

* Peter A. Muennig and Sherry A. Glied Health Affairs Oct. 7, 2010

Don’t handle your care needs in a BAD MEDICAL NEIGHBORHOOD!!

Unaccountable care, lack of organization, DO NOT GO THERE ALONE !!

Be wise when you pay for care, KNOW WHAT YOU BUY!!

“ We don't have a health care delivery system in this country. We have an expensive plethora of uncoordinated, unlinked, micro systems, each performing in ways that too often create sub-optimal performance, both for the overall health care infrastructure and for individual patients." George Halvorson, from “Healthcare Reform Now

Coordination -- we do NOT know how to play as a team

“We do kidney transplants and dialysis more often than anyone, but we need to, because patients are not given the kind of coordinated primary care that would prevent chronic complications of renal and heart disease from becoming acute.”

George Halvorson (CEO Kaiser) from “Healthcare Reform Now”

The Diabetic needs A long-term comprehensive relationship with a Personal Physician empowered

with the right tools and linked to their care team.

The Joint Principles: Patient Centered Medical Home Personal physician - each patient has an ongoing relationship with a personal

physician trained to provide first contact, and continuous and comprehensive care Physician directed medical practice – the personal physician leads a team of

individuals at the practice level who collectively take responsibility for the ongoing care of patients

Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or arranging care with other qualified professionals

Care is coordinated and integrated across all elements of the complex healthcare community- coordination is enabled by registries, information technology, and health information exchanges

Quality and safety are hallmarks of the medical home-

Evidence-based medicine and clinical decision-support tools guide decision-making; Physicians in the practice accept accountability voluntary engagement in performance measurement and improvement

Enhanced access to care is available - systems such as open scheduling, expanded hours, and new communication paths between patients, their personal physician, and practice staff are used

Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home- providers and employers work together to achieve payment reform

14

PopulationHealth

System Integrator

PatientExperience

The System Integrator

Creates a partnership across the medical

neighborhood

Drives PCMH primary care redesign

Offers a utility for population health and financial management

Per Capita Cost

Productivity

The Quadruple AimReadiness, Experience of Care, Population Health,

Cost

• For Diabetes you need a Captain for the ship

• You need a place of command and control

• You need a horizontal platform from which to launch vertical weapon systems

• You need somewhere and someone to hold accountable

So simple!So much!

If you scan the world for value based healthcare, you will find a common element: a relationship-based team with a project manager! A comprehensivist that can command and control in an accountable system.

Patientis the center

of theMedical Home

Population Health

Patient-Centered

Care

Refocused Medical TrainingPatient &

Physician Feedback

Advanced IT Systems

Access to Care

Team-Based Healthcare

Delivery

Decision Support Tools

Model adapted from theNNMC Medical Home

Enhancing Health and the Patient Experience

Medical Home Model

Superb Access to Care

Patient Engagement in Care

Clinical Information Systems

Care Coordination

Team Care

Patient Feedback

Publically Available Information

Defining the Care Centered on Patient

36.3% Drop in hospital days32.2% Drop in ER use 9.6% Total cost 10.5% Inpatient specialty care costs are down18.9% Ancillary costs down 15.0% Outpatient specialty down

Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US, K. Grumbach & P. Grundy, November 16th 2010

Smarter Healthcare…

Patient Centered Medical Home in Washington in State provided great example of how states can lower spending by reducing hospital care and expanding access to primary care providers. Acute care spending there was 18 percent below the national average. Inpatient stays per beneficiary were 35 percent below the national average.

Ref Health Affairs 7 July 2011 .http://healthaffairs.org/blog/2011/07/07/medicaid-spending-variations-driven-more-by-volume-than-price-says-study-in-new-health-affairs/ http://content.healthaffairs.org/content/30/7/1316.full

OPM $39 Billion Book with Accountable CarePatient at the center

24-7 clinician phone response Provide open scheduling. Provide care management and

coordination by specially-trained team members.

Use an EHR with decision support. Use CPOE for all orders, test

tracking, and follow-up. Medication reconciliation for every

visit. Prescription drug decision support. Implement e-prescribing.

Pre-visit planning and after-visit follow-up for care management.

Offer patient self-management support.

Provide a visit summary to the patient following each visit.

Maintain a summary-of-care record for patient transitions.

Email consultations. Telephone consultations. The development of care

plans. Performance outcome measures.

Public Health Prevention

Specialists

PCMH in Action Vermont “Blueprint” model

Community Care Team

Nurse CoordinatorSocial Workers

DieticiansCommunity Health Workers

Care Coordinators

Public Health Prevention HEALTH WELLNESS

Hospitals

PCMH

PCMH

Health IT Framework

Global Information Framework

Evaluation Framework

Operations

A Coordinated Health System

1 2 3 4 5$300,000,000

$320,000,000

$340,000,000

$360,000,000

$380,000,000

$400,000,000

$420,000,000

IMPACT OF MEDICAL HOME SAVINGS ACROSS TOTAL POPULATION

YEARS

INC

RE

ME

NT

AL

CO

ST

P

ER

YE

AR

Vermont Financial Impact

Payment reform requires more than one method, you have dials, adjust

them!!!fee for health”

“fee for outcome”

“fee for process” “fee for belonging

“fee for service”

“fee for satisfaction”

Reinventing Medicaid: State PCMH Innovations Show Promising Results New Payment Incentives – 17 states evaluated

Monthly care management fees. Most of the states studied pay patient-centered medical homes a per-member per-month fee averaging about $3 to $6. PAY FOR HIT Meaningful USE

Enhanced fee-for-service payments. Medicaid strategy rewards "well care" more highly than "sick care."

Network payments. North Carolina and Vermont pay networks or teams to support patient-centered medical homes.

Pay-for-performance. Nebraska, Oklahoma, and Pennsylvania are using performance-based payments. to complement other payments to patient-centered medical homes. Pennsylvania practices that have met certain performance criteria can share in any savings they generate.

Medicaid plans and commercial insurers. Seventeen states are participating or plan to participate in multipayer patient-centered medical home initiatives. Eight will add Medicare as a payer in 2011

Citation -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results," Health Affairs, July 2011 30(7):1325–34.

Care Coordination Payments To Practices In State Patient-Centered Medical Home Initiatives

Initiative PaymentAdjusted for patient

Adjusted for medical home level

Enhanced payment to practiceMedicaid managed care organizations

Iowa: IowaCare Medical Home Model $1.50–$3.00 No Yes Yes, based on performance No

Maine: Patient-Centered Medical Home Pilota $3.00–$7.00b No No No No

Maryland: Patient Centered Medical Home Pilot $4.68–$8.66c Yes Yes Yes, based on performance Yes

Massachusetts: Patient-Centered Medical Home Initiative $2.10–$7.50 Yes No Yes, lump sum based on performance Yes

Michigan: Primary Care Transformation Demonstration Projecta $3.00–$4.50 Yes No Yes, based on performance Yes

Minnesota: Health Care Homes Programa $10.14–$79.05d Yes No No Yes

Nebraska: Medicaid Medical Home Pilot Program $2.00–$4.00 No Yes Yes, based on performance No

New York: Adirondack Medical Home Demonstration Projecta $3.50 No No No Yes

North Carolina: Community Care of North Carolinaa,e $2.50–$5.00 Yes To be determined No No

Oklahoma: SoonerCare Choice $2.93–$8.41 Yes Yes Yes, lump sum based on performance No

Pennsylvania: Chronic Care Initiativea $3.00–$8.50f Yes Yes Yes, lump sum based on performance Yes

Rhode Island: Chronic Care Sustainability Initiativea $3.00 No NoYes, lump sum based on hiring a nurse care manager Yes

Vermont: Blueprint for Healtha $1.20–$2.39 No Yes Variesg Yes

Washington: Multi-PayerMedical Home Reimbursement Pilot $2.00–$2.50 No No Yes, based on performance Yes

• SOURCE Author’s analysis of state government information. NOTES The

Physician Practice Size

(# of patients) Level 1+ Level 2+ Level 3+

< 10,000 $4.68 $5.34 $6.01

10,000 - 20,000 $3.90 $4.45 $5.01

> 20,000 $3.51 $4.01 $4.51

PMPM Payment: Commercial Population

Level of PCMH Recognition

28

Tier Major Condition Groups Minutes of Work PMPM PMPM Payment

0 None N/ A N/ A

1 3-Jan 15 $10.14

2 6-Apr 30 $20.27

3 9-Jul 60 $40.54

4 10+ 90 $60.81

PCMH is non-political – the right POV for delivery transformation

“We never abandoned advocating newModels of care. We’ve long pushed folksto realize that Delivery reform is the key.”The patient-centered medical home iscore.

“We included the attached chapter on PCMH in our book. and have a new publication on ACOs coming out in January.”

Where do you train the Workforce?

OR?

…Requires a Smarter Healthcare Workforce

Basic

Descriptive Analytics

Performance Metrics

Advanced Analytics

Intelligent

BreakawayPassionate sponsor

of analytics

Pride in the gut based decision

Significant manual input

Predictive modeling

Contextual business

rulesData warehouses, governance and production reporting

Isolated reporting & analysis systems

Integrated information

Leverage cross- departmental &

functional data to derive actionable

insight

Performance messages widely communicated

Single version of truth

Personalized & role based

portal

Operational buy-in to performance analysis

driving decisionsRobust feedback loop

Analytics embraced & integrated into every day decisions & operations

Collaboration & workflow tools to aid planning & info sharing

Communication & Culture

Monitoring, Prediction,

ActionAutomated

analysis/alert

Leverage structured & unstructured

data for decision making

Real-Time Decision Support

Test and LearnCulture

Analytics Maturity Landscape

Spreadsheets

Adaptive Machine Learning

Patients love to see meaningful information about themselves and it take IT tools to

If you give patients educational materials with their name on it and with their data analyzed in it, they will read it, pour over it and discuss it with you.

If you tear off a generic sheet and give it to them, it often goes in the waste basket. If you give patients an analysis of their health risk AND if you include a “what if” scenario, i.e., what will their health risk be if they make a change; you can prove to them,

“if you the healer make a change, it will make a difference to your patient.”

• Build the foundation, the horizontal platform, a place of accountability – PCMH that allows HIT to be paid for.

• Really engage your patients find out what they need and become very patient centered

• Integrate value base purchasing with PCMH in your plan designee (understand what the buyer wants)

• Stop teaching the past you are in a world of Data, teams, actionable information

• Integrate Health and Sick care

• GIVE US LEADERSHIP - SHOW US THE WAY!

Recommendations

35

Payment Model Component PMPM Payment

Care management payments Up to $2.50 PMPM

Pay-for-performance payments Up to $2.50 PMPM

Payment Model Component PMPM Payment

Practice transformation cost payments (year 1 only)

$1.67 PMPM

Performance bonus (beginning in year 2) Up to $2.38 PMPM (value based on performance)

Risk-adjustment Up to $1.67 PMPM (only for practices with above average patient panel risk profiles; amount varies by practice)

Payment Model Component PMPM Payment

Practice support payments $1.50 PMPM

$0.60 PMPM (ages 0-17)

$1.50 PMPM (ages 18-64)

$5.00 PMPM (ages 65-74)

$7.00 PMPM (ages 75+)

Shared savings Value based on performance

Care management payments

I) if quality care exists in your community, use it2) Demand improved primary care (and be willing to pay for the transformation if in the long run it saves you Money and it does it) Communities need to be taught how to recruit and retain a primary care physician. There is a lot of work that has been done on this. 3) Seek out and use “Patient Centered Medical Homes” for health care4) Find physicians who are trying to conquered the digital divide5) Find a doctor comfortable with moving into the future with data, populating management, 6) Demand a focus on quality7) Demand provides in your community to collaborate, collaborate, collaborateIf there is a community health center (CHC), a rural health clinic, and a critical access (or small rural hospital) in your community, encourage collaboration8) Encourage mental health and primary care to work together (the Brain is connected to the body) 9) Work to build a healthy community integrate health and sick care