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Patient-Centered Medical Home:Navigating through Recognition and Rewards

Catherine ChuterProduct Marketing

50 years ago, half of all doctors in America practiced primary care.

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Today, fewer thanone in three

doctors are PCPs.

Primary Care Crisis by the numbers

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SOURCE: http://primarycareprogress.org/learn/the-issuehttp://www.nachc.com/pressrelease-detail.cfm?pressreleaseID=897

patients useERs and Urgent

Care clinics instead

of going to a primary care

doctor.

Americansdo not

have access to adequate

primary care.

1 in 5 60m+ 14%further

increase in demand for primary care doctors by

2020.

Considering Primary Care

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First Line of CareAdults in the U.S. who have a primary care physician have 33% lower health care costs and a 19% lower chance of dying than those who see only a specialist.

April 16th

MACRA, H.R. 2, made law• Strong incentives and

support systems included to encourage PCMH adoption

• APM participants may depart from the MIPS program and receive a 5% bonus each year (on top of any current APM payment structures)

News from Washington:

MACRA (SGR repeal bill) represents continuation of the shift toward value

SOURCE: The Medicare Access and CHIP Reauthorization Act of 2015; Advisory Board analysis.

2.APM participants who are close to but fall short of APM bonus requirements will not qualify for bonus but can report MIPS measures and receive incentives or can decline to participate in MIPS.

Merit-Based Incentive Payment System1

2020: -5% to +15%

2019: -4% to +12%

2022 and on: -9% to +27%

2021: -7% to +21%2018: Last year of separate

MU, PQRS, and VBM penalties

2019 - 2024: 5% participation bonus2019 - 2020: 25% Medicare revenue requirement

2021 and on: Ramped up Medicare or all-payer revenue requirements

1. Positive adjustments may be scaled by a factor of up to 3 times the negative adjustment to ensure budget neutrality. Actual positive adjustments may be lower than numbers shown here. In addition, top performers may earn additional adjustments of up to 10 percent.

Advanced Alternative Payment Models22

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ACO

PQRSPCMHAPMs

MSSP

MUEHR

HCCICD-10

ANSIMIPS

MACRA

ACA

IRM

Through MACRA health care professionals will receive a 5%

bonus each year* just by participating in an APM and

adhering to physician-reviewed quality measures.

PCMHAPMsMACRA

*Starting 2019 and continuing through 2024

Why PCMH?

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What the Patient-Consumer Wants

SOURCE: 2014 Primary Care Consumer Choice Survey, Marketing and Planning Leadership Council interviews and analysis.

For patients, access

comes first.

Service • Provider education on illness and wellness • Provider continuity

Affordability • In-network status • Eliminated out of pocket charges

Access and Convenience •Walk in availability, less than 30 minutes wait • Lab tests. X-rays, pharmacy onsite • 24/7 access • Same day appointment availability •Geographic proximity

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EHR Connectivity& Interoperability

Data Registries

Patient & Provider

Portals

Data Warehousing &

Mining

Acute Care

PHARMACY

SPECIALTY

CARE

PATIENT/FAMILY SUPPORTSHOME

CARE

ACUTE CARE

EMERGENCY CARE

SUPPORTIVE/

PALLIATIVE

CARE

TELEHEALTH

LONG TERM CARE

Medical Home

Benefits of Becoming a PCMH

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58% increase in clinician satisfaction

66% increase in staff satisfaction

11% increase in practice revenue

14% increase in clinician salariesSOURCE: http://primarycareprogress.org/pcmhL. M. Kern, R. V. Dhopeshwarkar, A. Edwards et al., "Patient Experience Over Time in Patient-Centered Medical Homes," American Journal of Managed Care, May 2013 19(5):403–10.

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Gaining Recognition

PCMH Recognition Programs

17 Source: The Urban Institute, "Patient-Centered Medical Home Recognition Tools: A Comparison of Ten Surveys' Content and Operational Details”, May 2011

Nationwide Payer PCMH Programs

18 Source: http://www.theverdengroup.com/payer-pcmh-programs-nationwide/

NCQA PCMH Growth 2008-2013

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SOURCE: http://www.ncqa.org/Portals/0/Events/BehindtheEnhancements_FINAL.pdf

12/31/08 12/31/09 12/31/10 12/31/11 12/31/12 12/31/130

5,000

10,000

15,000

20,000

25,000

30,000

35,000

214 1,976

7,676

16,191

24,544

34,492

28 3831,506

3,3025,198

6,762

Clinicians Sites

PCMH Recognition Through NCQA

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Six “Must-Pass” Elements

✔✔✔✔

✔✔

1. Patient-Centered Appointment Access

5. Referral Tracking and Follow-Up6. Implement Continuous Quality Improvement

4. Care Planning and Self-Care Support

3. Use Data for Population Management

2. The Practice Team (Team-Based Care)

PCMH Recognition Through NCQA

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Three Levels of Recognition

✔

✔✔

Level 1: 35-59 points

Level 3: 85-100 points

Level 2: 60-84 points

“The patient-centered medical home has the potential to change the interaction between patients and physicians. Patients can no longer be silent partners in their care— they are active participants in managing their health with a shared goal of staying as healthy as possible.”

-Margaret E. O’Kane, NCQA President

Challenges

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Seek a PCMH vendor who followsthese guidelines

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Provides educational materials about the transition

Determines where your practice stands for PCMH requirements

Puts together a work plan for achieving recognition

Connects with other practices that have successfully transitioned

Advocates on your behalf with payers to ensure financial rewards

athenahealth’s Accelerator Program

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athenahealth was first to undergoNCQA PCMH Corporate Review

athenahealth covers about 60% of the points required for NCQA’s highest level of PCMH

recognition

0

20

40

60

80

100

85

35.25

45.5

Minimum amount of points for NCQA Level 3

Practice Responsibility

4.25

Athena Enabled

Auto Credit*

NCQALevel 1

NCQALevel 2

*pre-validated NCQA points

*practice support points

athenahealth PCMH Accelerator Program

What’s Next?

• PCMH Transition Resource Center:o PCMH2014 self-assessment

o Guidance materials

o Accelerator team

o athenaNet support

o Quality Management tools

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of our clients holdLevel 3 PCMH recognition

77.3%

of those recognized providers are on

athenahealth8%

providers successfully recognized as a PCMH

on athenahealth4,07

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2014 Best in KLAS

#1 Practice

Management System

(1-10, 11-75 physicians)

#2 Practice

Management System

(Over 75 physicians)

#2 EHR

(1-10, 11-75

physicians)

#2 PatientPortal

#2Overall Physicia

n Practice Vendor

“2014 Best in KLAS Awards: Software & Services,” January, 2015. © 2015 KLAS Enterprises, LLC. All rights reserved. www.KLASresearch.com

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Thank You