patient centered medical homes: lay of the land
TRANSCRIPT
Patient‐Centered Medical Homes:Lay of the Land & Lessons Learned
Asaf Bitton, MD MPHDivision of General Medicine, Brigham and Women’s HospitalDepartment of Health Care Policy, Harvard Medical School
Massachusetts League of Community Health CentersCommunity Health Institute
May 11th, 2011
Overview
Current state of primary care PCMH in theory and practice Practice transformation Payment Evaluation
Moving beyond the walls of PCMH A way forward Discussion
A “Perfect Storm” Unsustainable cost growth, inadequate quality, fragmented care, workforce shortage, aging population
Michael Patmas MD, OHSU, 2006
Reinventing Our Delivery System
“Current care systems cannot do the job. Trying harder will not work. Changing systems
of care will.”
Institute of Medicine. Crossing the Quality Chasm. 2001
Invention vs. Innovation
Kitty Hawk, 1903 DC‐3, 1935
PCMH Joint Principles
Patient
Personal Physician
Enhanced Access
Payment Reform
Care Coordination
Physician Led Practice
Quality/ Safety
Whole Person
“Home Team, Centered Around the Patient”Connected through HIT
Nutting et al , Health Affairs, March 2011
PCMH
Primary Care Pillars
Chronic Care Model
Robust HIT
Patient Centered
Common Elements of PCMH
Personal Physician Team‐based practice Expanded access Emphasis on coordination of care Proactive population health management Care facilitation and data analysis with HIT New forms of payment
Fields et al, Health Affairs, May 2010
Does HIT = Medical Home?
Necessary but alone not sufficient Enables coordinating connections
Major Current HIT Needs: Robust decision support Registry tools Tools enabling team function and pt engagement Personal health records
Bates D and Bitton A. “The Future of HIT in the PCMH”. Health Affairs. April 2010.
PCMH Recognition: New NCQA Standards
Enhance Access/Continuity Identify/Manage Patient Populations Plan/Manage Care Provide Self‐Care Support/ Community Resources
Track/Coordinate Care Measure/Improve Performance
How to Transform?
Changing provider behavior is difficult Physician socialization – “I do everything” Patient segmentation Challenge notions of continuity & professional identity
New competencies needed Practice re‐design and Leadership Micro‐system change
Modes of catalyzing transformation External facilitation vs. care collaboratives
Alignment of incentives is crucial
RI
Multi-Payer pilot discussions/activity
Identified pilot activity
No identified pilot activity – 6 States
National PCMHDemonstration Activity
Source: PCPCC
NCQA Recognized Sites, 2010
18 states AZ, CO, GA, LA, ME, MD, MI, NH, NY, NC, ND, OK,OH, OR, PA, RI, TN, VT
Genesis‐ State was the convening entity (9)‐ Local efforts involved with primary care reform (18)‐ Medicare
Payer type 18 Single Payer (67%) 9 Multi‐Payer (33%)
Current PCMH Demonstrations with Payment Reform
Bitton A, Martin C, Landon B. “A National Survey of PCMH Demonstrations. JGIM. June 2010.
Results for Current National Demos
Practices 4,659
Physicians 14,389
Patients 4,900,000
Bitton A, Martin C, Landon B. “A National Survey of PCMH Demonstrations. JGIM. June 2010.
Models for PCMH Payment Enhanced Fee for Service (FFS) Higher technical fees New codes for phone call and emails Higher volume with mid‐level providers
Capitation Comprehensive Risk Adjusted Payment Model (NY/MA)
3 part model FFS Enhanced pay for performance Care management fees (per person per month)
Payment for Current National Demos
Per Person Per Month (PPPM) Payments 96%
Range of PPPM Payments $0.50 to $9.00
Range of Additional Revenue per MD/yr $720 to $91,146(median $22,834)
Upfront or Start-up Payments 42%
Bitton A, Martin C, Landon B. “A National Survey of PCMH Demonstrations. JGIM. June 2010.
Payment Reform Questions
How much is enough? How far along the payment spectrum do we go? Will the payers play? How to continue to support transformation? What about ACOs?
PCMH Evaluation: How do you know if this works?
Multi‐Dimensional Evaluations
Transformation
Efficiency Quality Experience
Patient Staff
Education
Early PCMH ResultsProject Hosp ER Visits Quality Pt
ExperienceTotal $ per patient/yr
Group Health Cooperative (WA)
‐6% (all)‐13% (ACSC)
‐29% Improved Improved in 5 / 7 scales
‐$120
Geisinger (PA) ‐18% (all)‐36% (re‐ad)
NA NA NA ‐7% (+5% to ‐18%)
(Not Stat Significant)
NDP (national) NA NA Improved Slightly worse (NS)
*Practice Rev +2% to 12%
Community Care of North Carolina*
‐40% NA Improved asthma, DM
NA ‐$516
Colorado Medical Homes for Children*
‐18% ‐16% NA NA ‐$169 (all)‐$530 (c. dz)
Intermountain (UT)* ‐5% (all)‐19% (c.dz)
0% (all)‐7% (c.dz)
NA NA ‐$640
North Dakota BCBS* ‐6% ‐24% NA NA ‐$530
Vermont Blueprint* ‐11% ‐12% NA NA ‐$215
*Not peer reviewed ACS= ambulatory care sensitive conditions c dz = chronic disease NS = not statistically significant re-ad = readmissions
Moving Beyond the Walls of the PCMH
Patient Engagement
Did anyone ask the pts? Is PCMH for everyone, or just with chronic dz? Including them in the change process? Keeping patients at the core, not just in name only Helping pts to better care for themselves Behavioral economics Group visits Proactive self‐mgmt support Personal health records
PCMH Neighbor (ACP)
Specialists that communicate, coordinate and integrate bi‐directionally with PCMH
Ensure appropriate and timely consultations
Increase effective flow of information
Clarify patient co‐management responsibility
PCMH Neighbor (ACP)
How to get there?
Recognition process
Care Coordination Agreements Define type of interaction Responsibility for the elements of care Expectations for information exchange
The Medical Neighborhood Extends around PCMH “Core” and “Peripheral” neighbors Varies by community and provider network arrangement
Requires formal, reciprocal care agreements
Enhanced by efficient information transfer (HIT)
Shared risks and incentives for outcomes
Compatible with different payment structures
A stepping stone to ACOs
Source: Pham H, Journal of General Internal Medicine, 2010
Learning from termites
Kjell Bjartveit
“It can be done”
Change
“Possibility derives less from effort than from redesign” Berwick and Luo, 2010
“We ourselves engage in change only as we discover that we might be more of who we are by becoming something different” Wheatley and Kellner‐Rogers, A Simpler Way
Concluding Thoughts PCMH is about improving care through teams, HIT, and a renewed focus on the pt
The PCMH model is already widespread
Early results are promising Many questions remain
PCMH fits into the broader reform agenda Optimism is a strategic imperative
