Presentation on theme: "Shari M. Erickson, MPH Director, Regulatory and Insurer Affairs"— Presentation transcript:
1 Shari M. Erickson, MPH Director, Regulatory and Insurer Affairs The Patient Centered Medical Home (PCMH) Activities, Findings, and Challenges 15th Annual NHMA Conference March 19, 2011Shari M. Erickson, MPH Director, Regulatory and Insurer Affairs
2 Presentation Outline Joint Principles Specialty Care Connections PCMH Recognition programsEfforts to test the PCMH modelPCMH Evaluations & Results
3 ACP, AAFP, AAP, and AOA Joint Principles of the PCMH Team-based care:NP/PARN/LPNMedical AssistantOffice StaffCare CoordinatorNutritionist/EducatorPharmacistBehavioral HealthCase ManagerSocial WorkerCommunity resourcesDM companiesOthers…Personal physician in physician-directed practiceWhole person orientationCoordinated care, integrated across settingsQuality and safety emphasisEnhanced patient access to careSupported by payment structure that recognizes services and valueSOURCE: demonstrations/jointprinc_05_17.pdf (March 2007)
4 “Neighbors” Endorsing the Joint Principles American Academy of Hospice and Palliative MedicineAmerican Academy of NeurologyAmerican College of CardiologyAmerican College of Chest PhysiciansAmerican College of Osteopathic Family PhysiciansAmerican College of Osteopathic InternistsAmerican Geriatrics SocietyAmerican Medical AssociationAmerican Medical Directors AssociationAmerican Society of Addiction MedicineAmerican Society of Clinical OncologyAssociation of Professors of MedicineAssociation of Program Directors in Internal MedicineClerkship Directors in Internal MedicineInfectious Diseases Society of AmericaSociety for Adolescent MedicineSociety of Critical Care MedicineSociety of General Internal MedicineThe Endocrine Society
5 Presentation Outline Joint Principles Specialty Care Connections PCMH Recognition programsEfforts to test the PCMH modelPCMH Evaluations & Results
6 Complex DeliveryHealth care delivery is complex – e.g., the typical primary care physician coordinates care with 229 other physicians working in 117 practicesH H Pham, et al Ann Intern Med. 2009;150:
7 Nearly Half of U.S. Adults Report Failures to Coordinate Care Percent U.S. adults reported in past two years:No one contacted you about test results, or you had to call repeatedly to get resultsTest results/medical records were not available at the time of appointmentYour primary care doctor did not receive a report back from a specialistAny of the aboveDoctors failed to provide important medical information to other doctors or nurses you think should have itYour specialist did not receive basic medical information from your primary care doctorSource: S. K. H. How, A. Shih, J. Lau, and C. Schoen, Public Views on U.S. Health System Organization: A Call for New Directions (New York: The Commonwealth Fund, Aug. 2008).
8 PCMH Neighbor ModelProposes a Framework for Interactions between PCMH practices and Specialty Practices:A scaffolding upon which Care Integration and Information Exchange can be builtRestore Professional Interactions for Patient Centered CareImprove Care Transfers and Transitions to enhance Safety and Stewardship/ reduce wasted resourcesACP-CSS Workgroup Policy Paper available at:
9 PCMH Neighbor Model (cont.) Defines concept of PCMH-N practices as practices that:Communicate, coordinate and integrate bidirectionally with PCMHEnsure appropriate and timely consultations and referralsEnsure effective flow of information;Address issues of responsibility in co-management situations;Support patient-centered careSupport the PCMH practice as the provider of whole person primary care to the patientACP-CSS Workgroup Policy Paper available at:
10 PCMH Neighbor Model: How Does It Work? Via Care Coordination Agreements, which promote better communication and care coordination by defining:Types of InteractionsPre-consultation exchange to expedite/ prioritize careConsultation /procedureComanagementShared carePrincipal careResponsibility for the elements of careExpectations for information exchangeACP-CSS Workgroup Policy Paper available at:
11 Additional Considerations for the PCMH Neighbor Model: Incentives (both nonfinancial and financial) should be aligned with the efforts and contributions of the PCMH-N practice to collaborate with the PCMH practice.A PCMH-N recognition process should be explored.ACP-CSS Workgroup Policy Paper available at:
12 The PCMH Model and Accountable Care Organizations (ACOs) The PCMH, in conjunction with the health care “neighborhood” in which it resides, is a critical foundation of ACOsSource: Premier Healthcare Alliance
13 Support for Primary Care Foundation for ACOs “Some experts have advocated requiring a strong primary care foundation for Accountable Care Organizations (ACOs). Please indicate the degree to which you support or oppose establishing standards for primary care capacity as a condition for qualifying for ACO payment.”Strongly oppose2%Not sure1%Oppose7%Neither support nor oppose12%Strongly support46%Support31%* Percentages may not be equal to 100 percent because of rounding.Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, July 2010.
14 Presentation Outline Joint Principles Specialty Care Connections PCMH Recognition programsEfforts to test the PCMH modelPCMH Evaluations & Results
15 How do you Know a PCMH When you See One? Process needed to recognize practices that have and use the capability to provide patient-centered carePractice recognition provides purchasers (employers, government) and patients with prospective assurance that the practice has capabilitiesRecognized PCMHs also must be accountable for quality of care by reporting on evidence-based clinical and patient experience measures—provides retrospective assuranceNational Committee on Quality Assurance (NCQA) released the PPC-PCMH in January 2008; Revised version released in January 2011Other entities are also developing or implementing PCMH recognition/accreditation processes – AAAHC, The Joint Commission, URAC
16 Guidelines for PCMH Recognition and Accreditation Programs The AAFP, AAP, ACP, and AOA released these Guidelines in March 2011 to assist with the development and use of these programs.These Guidelines state that all Patient-Centered Medical Home Recognition or Accreditation Programs should:Incorporate the Joint Principles of the Patient-Centered Medical HomeAddress the Complete Scope of Primary Care Services (including comprehensive, whole person care)Ensure the Incorporation of Patient and Family-Centered Care Emphasizing Engagement of Patients, their Families, and their CaregiversEngage Multiple Stakeholders in the Development and Implementation of the ProgramAlign Standards, Elements, Characteristics, and/or Measures with Meaningful Use RequirementsIdentify Essential Standards, Elements, and CharacteristicsJoint Guidelines for PCMH Recognition and Accreditation Programs available at:
17 Guidelines for PCMH Recognition and Accreditation Programs (cont.) All Patient-Centered Medical Home Recognition or Accreditation Programs should:Address the Core Concept of Continuous Improvement that is Central to the PCMH ModelAllow for Innovative IdeasAcknowledge Care Coordination within the Medical NeighborhoodClearly Identify PCMH Recognition or Accreditation Requirements for Training ProgramsEnsure Transparency in Program Structure and ScoringApply Reasonable Documentation/Data Collection RequirementsConduct Evaluations of the Program’s Effectiveness and Implement Improvements Over TimeJoint Guidelines for PCMH Recognition and Accreditation Programs available at:
18 Presentation Outline Joint Principles Specialty Care Connections PCMH Recognition programsEfforts to test the PCMH modelPCMH Evaluations & Results
19 Overview of PCMH Commercial Pilot Activity (cont.)* = Identified to have at least one private payer medical home pilot under development or underway* As tracked by the American College of Physicians and the Patient-Centered Primary Care Collaborative (updated March 2011)
20 Initiatives to Advance Medical Homes in Medicaid/ CHIP = Identified to have a Medicaid and/or CHIP medical home initiative underway or under developmentSource: National Academy for State Health Policy (NASHP) State Map (http://nashp.org/med-home-map), March 2011
21 Medicare Multi-Payer Advanced Primary Care Initiative States = States participating in the Medicare Multi-Payer Advanced Primary Care InitiativeSource: CMS, March 2011 (http://www.cms.gov/demoprojectsevalrpts/ md/itemdetail.asp?itemid=cms )
22 Combined Commercial, Medicaid/ CHIP, and Medicare FFS PCMH Activity = Identified to have at least one private payer medical home pilot under development or underway= Identified to have a Medicaid and/or CHIP medical home initiative= Identified as a Medicare APC State, which includes private payers, Medicaid and/or CHIP, and Medicare FFS= Identified to have both a private payer and a Medicaid and/or CHIP medical home initiative* As tracked by the American College of Physicians (updated March 2011)
23 More Information on PCMH Demonstration Projects OR the PCPCC website:See the ACP website:
24 Presentation Outline Joint Principles Specialty Care Connections PCMH Recognition programsEfforts to test the PCMH modelPCMH Evaluations & Results
25 PCMH Evaluations Key Questions Under Investigation: What does it take to become a medical home?Do PCMHs improve:Clinical Quality?Patients’ Experiences?Physician/Staff Experience?Efficiency?Is this sustainable/ are practices financially stable?
26 Community Implications - Results of PCMH Projects to Date (Integrated Systems) Group Health Cooperative of Puget Sound29% reduction in ER visits; 16% reduction in hospital admissions$10 PMPM reduction in total costsImprovements in diabetes and heart disease careGreater staff satisfaction; less burnout; improved primary care recruitment and retentionGeisinger Health System18% reduction in hospital admissions7 % reduction in total PMPM costsImprovements in preventive, diabetes, and heart disease careROI greater than 2 to 1Source: PCPCC Outcomes of Implementing PCMH Interventions (November 2010) -
27 Community Implications –Results of PCMH Projects (Private Payer Sponsored) BCBS of South Carolina-Palmetto36% fewer hospital days and 32% fewer ED visits among PCMH patients when compared with control patients6.5% reduction in total medical costs for PCMH vs. controlMetropolitan Health Networks-Humana (FL)Hospital days per 1000 customers dropped by 4.6 percent compared to an increase of 36 percent in the control groupHospital admissions per 1000 customers dropped by three percent, with readmissions running six percent below Medicare benchmarksEmergency room expense rose by only 4.5% for the PCMH group compared to an increase of 17.4% for the control groupSource: PCPCC Outcomes of Implementing PCMH Interventions (November 2010) -
28 Community Implications – Results of PCMH Projects (Medicaid Sponsored) Colorado Medicaid and SCHIPMedian annual costs $785 vs $1000 in controlsReduction in ER visits & hospitalizationsMore well-child visits (72% vs 27% in controls)Lower median costs for children with chronic conditions ($2,275 versus $3,404 in controls)Source: PCPCC Outcomes of Implementing PCMH Interventions (November 2010) -
29 PCPCC Evidence Summary More Results…PCPCC Evidence SummaryAnd on the PCPCC website…
30 Some Challenges and Questions for PCMH Going Forward Is the PCMH model sustainable over the longer term?What does it cost – to practices, payers, purchasers, and others?Is the PCMH Neighborhood model achievable and can appropriate incentives be put into place effectively?What role should the PCMH and PCMH Neighborhood play in the development of ACOs?How will other payment and delivery system reform efforts impact the development of the PCMH model?Will the PCMH model have a positive impact on recruitment and retention of the primary care workforce?How do we more fully engage employers and consumers in the model?How do we best understand and facilitate the necessary health IT?Can the model be effectively integrated into medical education?
31 Thank You!Shari M. Erickson, MPH Director Regulatory and Insurer AffairsQuestions?