the patient-centered medical home impact on cost and quality: an annual review of evidence
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Dr. Nwando Olayiwola, Associate Director, Center for Excellence in Primary Care, Assistant Professor, University of California, San Francisco addresses the 2014 Weitzman Symposium on The Patient-Centered Medical Home Impact on Cost and Quality: An Annual Review of EvidenceTRANSCRIPT
CHCI Weitzman symposium May 2014J. Nwando Olayiwola, MD, MPH, FAAFP
Associate Director, Center for Excellence in Primary CareAssistant Professor, Department of Family & Community Medicine
University of California, San Francisco
The Patient-Centered Medical Home’s Impact on Cost and Quality: A Review of the
Evidence from 2012-2013
AuthorsMarci Nielsen, PhD, MPH
Chief Executive Officer, PCPCC
J. Nwando Olayiwola, MD, MPH, FAAFPAssociate Director, Center for Excellence in Primary Care; Assistant Professor, Department of Family and Community Medicine, University of California, San Francisco
Paul Grundy, MD, MPHPresident, PCPCC; Global Director, Healthcare Transformation, IBM
Kevin Grumbach, MDProfessor and Chair, Department of Family and Community Medicine; University of California, San Francisco
Lisa Dulsky Watkins, MDFormer Associate Director, Vermont Blueprint for Health
ReviewersMelinda Abrams, MS
Vice President, Health Care Delivery System Reform; The Commonwealth Fund Asaf Bitton, MD, MPH
Instructor, Division of General Medicine, Brigham and Women's Hospital; Instructor, Department of Health Care Policy, Harvard Medical School
Mark GibsonDirector, Center for Evidence-Based Policy; Oregon Health & Science University
Bruce Landon, MD, MBA, MSc
Professor of Health Care Policy, Harvard Medical School; Professor of Medicine, Division of General Medicine and Primary Care; Beth Israel Deaconess Medical Center
Len Nichols, PhDDirector, Center for Health Policy Research and Ethics; George Mason University
Kavita Patel, MD Managing Director for Clinical Transformation and Delivery; Engelberg Center for Health Care Reform; Fellow, Economic Studies The Brookings Institution
Mary Takach, MPH, RNSenior Program Director; National Academy for State Health Policy
Take Home PointsPCMH evaluations over the past year reported
significant improvements across a broad range of clinical and financial outcomes
The PCMH is playing an increasingly critical role in delivery system reform, including ACOs and the medical neighborhood
Significant payment reforms continue to incorporate the PCMH
The Landscape: PCMH Momentum
NCQA Recognized PCMH By State – 12/31/10
Source: Analysis by the National Committee for Quality Assurance, Dec. 2010.
NCQA-Recognized Practices Across the United States
ME
VT
RI
NJ
MD
MA
DE
NY
WA
OR
AZ
NV
WI
NM
NE
MN
KS
FL
CO
IA
NC
MI
PAOH
VAMO
HI
OK
GA
SC
TN
MT
KY
WV
AR
LA
AL
INIL
SD
ND
TX
ID
WY
UT
AK
CA
CT
NH
MS
61–200 sites
21–60 sites
0 sites
1–20 sites
201+ sites
Source: Analysis by the National Committee for Quality Assurance, Oct. 2012.
4,937 sites & 23,396 clinicians as of 10/31/2012
PCMH Recognized Physicians and Sites: Growth Over Time
National Imperative: Triple Aim
Source : Berwick, Donald M., Thomas W. Nolan, and John Whittington. "The triple aim: care, health, and cost." Health Affairs 27.3 (2008): 759-769.
Methods• Examined medical home/PCMH studies published
between August 2012 and December 2013– Peer-reviewed scholarly articles– Industry reports
• Explored relationship between “medical home/PCMH” model of care and Triple Aim outcomes – Predictor variable: “Medical home” or “PCMH” – Outcome variables: Cost & utilization; care experience
(access & patient satisfaction); health outcomes (population health & preventive services)
• Resulted in 13 peer reviewed (academic) studies, and 7 industry reports
13 Peer-Reviewed (Academic) Studies• Alaska Southcentral Foundation• Colorado Multi-Payer PCMH Pilot• BlueCross BlueShield Michigan• Military Health System• Veterans Health Administration • New Hampshire Citizens Health Initiative• Horizon BlueCross BlueShield• EmblemHealth – New York• WellPoint - New York• UPMC Health Plan• Rhode Island Chronic Care Sustainability Initiative• University of Utah• Group Health Cooperative
• BlueCross BlueShield Alabama• Connecticut Health Enhancement Program• Horizon Blue Cross Blue Shield• BlueCross BlueShield Michigan• CareFirst BlueCross BlueShield• Oregon Coordinated Care Organizations• Highmark PCMH Pilot
7 Industry generated Reports
Key Point #1:PCMH evaluations report improvements across a broad range of clinical and financial outcomes
PCMH Peer Reviewed Peer Reviewed Outcomes
PCMH Industry Generated Industry Generated Outcomes
Key Point #2:PCMHs play a critical role in delivery system reform, including ACOs and the medical neighborhood
Public Health
Employers
Schools
Faith-Based Organizations
Community Centers Home
Health Hospital
Pharmacy Diagnostics
Specialty & Subspecialty
Patient-Centered Medical Home
Community Organizations
Connected via Health IT
$
$
PCMH: Foundation to ACOs & the Medical Neighborhood
Emerging Trends
ACO Climate and Opportunities
ACO Growth Over Time
Source: Muhlestein D. Accountable Care Growth in 2014: A Look Ahead. Health Affairs Blog. January 2014
ACOs by Sponsoring Entity
Source: Muhlestein D. Accountable Care Growth in 2014: A Look Ahead. Health Affairs Blog. January 2014
Estimated ACO Lives 2014
Source: Muhlestein D. Accountable Care Growth in 2014: A Look Ahead. Health Affairs Blog. January 2014
Key Point #3:Significant payment reforms continue to incorporate the PCMH
Payment Reform Drivers – Making the Case
Policy Influences
Sustainable Growth Rate (SGR)
• “Volume to Value”• Federal legislation = long term
adoption• Encourages more providers to
accept risk-based payments (5% Medicare increase)
• Repeal calls for PCMH as supportive framework
• Will lead to broader acceptance of PCMH and ACOs
State Medicaid Activity and Expansions
• “Volume to Value”• State based = short term
adoption• Oregon and Utah pioneers in
state Medicaid ACO• Providers bear some risk while
meeting quality benchmarks• State based reimbursements for
PCMH recognition important driver
Payment Reforms
Source: S. Guterman, M. Zezza, C. Schoen, Paying for Value: Replacing Medicare's Sustainable Growth Rate Formula with Incentives to Improve Care, The Commonwealth Fund, March 2013.
Private Sector Reforms• Commercial health plans moving from traditional
fee-for-service models• Transition from PCMH “demonstrations” to standard
business operations– Incentives for primary care– PCMH incentives– Care coordination reimbursements– PMPM add ons
Overview of Medicaid Medical Home Activity 42 State Medicaid/CHIP Programs Planning/Implementing PCMH
27 Making Medical Home Payments
Source: National Academy for State Health Policy State Scan, October 2012, http://www.nashp.org/med-home-map.
WA
OR
TX
CO
NC
LA
PA
NY
IA
VA
NE
OK
RI
AL
MD
MT
ID
KS
MNMA
ME
AZ
VT
MOCA
WY
NM
IL
WIMI
WV
SC
GA
FL
HI
UTNV
ND
SD
AR
INOH
KY
TN
MS
AK
Significant activity for Medicaid/CHIP PCMH advancement (15 states)
No PCMH Medicaid activity (8 states)
States making payments for PCMH (27 states)
NJ
DE
NH
CT
Overview of Medicaid Medical Home Activity47 State Medicaid/CHIP Programs Planning/Implementing PCMH
30 Making Medical Home Payments, 22 Involved in Multi-payer Pilots
WA
OR
TX
CO
NC
LA
PA
NY
IA
VA
NE
OK
RI
AL
MD
MT
ID
KS
MN NHMA
ME
AZ
VT
MOCA
WY
NM
IL
WIMI
WV
SC
GA
FL
HI
UTNV
ND
SD
AR
INOH
KY
TN
MS
AK
Significant activity for Medicaid/CHIP PCMH advancement (26 states + DC)
Medicaid multi-payer activity/involvement (22 states)
States making payments for PCMH (30 states)
NJ
DE
Source: National Academy for State Health Policy State Scan, May 2014, http://www.nashp.org/med-home-map.
CT
DC
WA
OR
TX
CO
NC
LA
PA
NY
IA
VA
NE
OK
AL
MD
MT
ID
KS
MN
ME
AZ
VT
MOCA
WY
NM
IL
WIMI
WV
SCGA
FLHI
UTNV
ND
SD
AR
INOH
KY
TN
MS
AK
National Momentum: Spread of Medical HomesAt Least One Payer in 49 States Testing PCMH
Multi-payer payment (22 states)
Identified pilot activity (49 states)
No identified pilot activity (1 state)
Source: Patient Centered Primary Care Collaborative and National Academy for State Health Policy, updated May 2014
DE
NH
RIMACT
NJ
The Year in Review: Case Study Snapshots
Veterans Health Administration Patient Aligned Care Team
• Optimize workflow and coordinate care through the use of an interprofessional “teamlet” model
• Enact advanced scheduling, such as same-day appointments
• Add phone consults and group appointments
National program5 million patients
ResultsPCMH Strategies
• 8% fewer urgent care visits
• 4% fewer inpatient admissions
• Decrease in face-to-face visits• Increase in phone encounters,
personal health record use, and electronic messaging to providers
Source: Rosland, A.M., Nelson, K., Sun, H., Dolan, E.D., Maynard, C., Bryson, C., Stark, R., Schectman, D., (2013). The Patient-Centered Medical Home in the Veterans Health Administration. American Journal of Managed Care. 1-4.
BlueCross BlueShield of Michigan Physician Group Incentive Program
Michigan3 million patients
ResultsPCMH Strategies• 13.5% fewer pediatric
ED visits• 10% fewer adult ED
visits
• 17% fewer inpatient admissions
• 6% fewer hospital readmissions
• Savings of $26.37 PMPM• $155 million in cost
savingsSource: Blue Cross Blue Shield of Michigan. Patient-Centered Medical Home Fact Sheet. July 2013. Retrieved from http://www.valuepartnerships.com/wp-content/uploads/2013/07/2013-PCMH-Fact-Sheet.pdf.
• Develop patient registries to track and monitor patients’ care
• Offer 24-hour patient access to a clinical decision-maker through
• extended office hours• telephone access• a linkage to urgent care
• Provide online patient resources that allow for electronic communication and greater patient access to medical information
UPMC Health Plan Medical Home Pilot
Pennsylvania 23,390 patients
ResultsPCMH Strategies
• 2.6% reduction in total costs• 160% ROI
• 2.8% fewer inpatient admission
• 6.6% increase in patients with controlled HbA1c
• 18.3% fewer hospital readmissions
• 23.2% increase in eye exams• 9.7% increase in LDL
screenings
• Practice-based nurses provide care management
• Create telehealth options for care managers to connect to patients when in-office visits are not possible or necessary
• Offer incentives to payers to enter into PCMH contracts
Source: Rosenberg, C.N., Peele, P., Keyser, D., McAnallen, S., & Holder, D. (2012) Results from a patient-centered medical home pilot at UPMC Health Plan hold lessons for broader adoption of the model. Health Affairs. 31(11).
CareFirst BlueCross BlueShield Maryland
Maryland1 million patients
ResultsPCMH Strategies
• $98 million in total cost savings
• 4.7% lower costs for physicians that received an incentive award
• 3.7% higher quality scores for panels that received incentives
• Quality scores for PCMH panels rose by 9.3% from 2011 to 2012
Source: CareFirst Blue Cross Blue Shield. Patient-centered medical home program trims expected health care costs by $98 million in second year. Press Release, June 2013. Retrieved from https://member.carefirst.com/wps/portal/!ut/p/c4/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hLbzN_Q09LYwN
• Use local care coordination teams to track high-risk members
• Create an infrastructure for nursing support, easily-accessible online tools and data, and targeted health programs
• Offer increased reimbursements to physicians based on performance in the program
Oregon Health Authority Coordinated Care Organizations (CCOs)
Statewide Medicaid program600,000 patients
ResultsPCMH Strategies
• 9% reduction in ED visits• 14-29% fewer ED visits for
chronic disease patients
• 12% fewer hospital readmissions
• 18% reduction in ED visit spending
• Reduced per capital health spending growth by >1%Source: Oregon Health Authority. (2013). Oregon’s Health System
Transformation: Quarterly Progress Report. Retrieved from http://www.oregon.gov/oha/Metrics/Documents/report-november-2013.pdf.
• Establish a primary care infrastructure that includes 450 PCMH practices and clinics
• Increase the use of outpatient care to promote prevention
• Increase well-care visits to adolescents to reduce unnecessary ED visits
• Provide follow-up care to patients within 7 days of being discharged
The Challenge of Studying the PCMH: The Right Metrics?
• Right metrics?– Gap in clinician satisfaction measures – tied to
workforce needs– Need for better/more patient satisfaction measures
of self-reported health status/well-being– Measures need to account for patient diversity,
socioeconomics and social determinants of health – Need for standard core measures – including
behavioral health and oral health integration– Stronger case for connection to health equity
• Right methods?– Study designs appropriate for investigating
complexity of health system reforms– Recognition that the model/philosophy is evolving– Evaluation often in the midst of multimodal
change processes
Source: Grumbach, Kevin. "The Patient-Centered Medical Home Is Not a Pill: Implications for Evaluating Primary Care Reforms." JAMA internal medicine 173.20 (2013): 1913-1914.
The Challenge of Studying the PCMH: The Right Methods?
Take Home PointsPCMH evaluations over the past year reported
significant improvements across a broad range of clinical and financial outcomes
The PCMH is playing an increasingly critical role in delivery system reform, including ACOs and the medical neighborhood
Significant payment reforms continue to incorporate the PCMH
Thank You!
Contact:J. Nwando Olayiwola, MD, MPH, FAAFPAssociate Director, Center for Excellence in Primary CareUniversity of California, San [email protected] Twitter: @DrNwando(415) 206-2970 (O)