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, 2011 Shari M. Erickson, MPH Director, Regulatory and Insurer Affairs

Presentation Outline Joint Principles Specialty Care Connections PCMH Recognition programs Efforts to test the PCMH model PCMH Evaluations & Results

ACP, AAFP, AAP, and AOA Joint Principles of the PCMH Team-based care: NP/PA RN/LPN Medical Assistant Office Staff Care Coordinator Nutritionist/Educator Pharmacist Behavioral Health Case Manager Social Worker Community resources DM companies Others… Personal physician in physician-directed practice Whole person orientation Coordinated care, integrated across settings Quality and safety emphasis Enhanced patient access to care Supported by payment structure that recognizes services and value SOURCE: http://www.acponline.org/running_practice/pcmh/ demonstrations/jointprinc_05_17.pdf (March 2007)

“Neighbors” Endorsing the Joint Principles American Academy of Hospice and Palliative Medicine American Academy of Neurology American College of Cardiology American College of Chest Physicians American College of Osteopathic Family Physicians American College of Osteopathic Internists American Geriatrics Society American Medical Association American Medical Directors Association American Society of Addiction Medicine American Society of Clinical Oncology Association of Professors of Medicine Association of Program Directors in Internal Medicine Clerkship Directors in Internal Medicine Infectious Diseases Society of America Society for Adolescent Medicine Society of Critical Care Medicine Society of General Internal Medicine The Endocrine Society

Presentation Outline Joint Principles Specialty Care Connections PCMH Recognition programs Efforts to test the PCMH model PCMH Evaluations & Results

Complex Delivery Health care delivery is complex – e.g., the typical primary care physician coordinates care with 229 other physicians working in 117 practices H H Pham, et al Ann Intern Med. 2009;150:236-242

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 results Test results/medical records were not available at the time of appointment Your primary care doctor did not receive a report back from a specialist Any of the above Doctors failed to provide important medical information to other doctors or nurses you think should have it Your specialist did not receive basic medical information from your primary care doctor Source: 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).

PCMH Neighbor Model Proposes a Framework for Interactions between PCMH practices and Specialty Practices: A scaffolding upon which Care Integration and Information Exchange can be built Restore Professional Interactions for Patient Centered Care Improve Care Transfers and Transitions to enhance Safety and Stewardship/ reduce wasted resources ACP-CSS Workgroup Policy Paper available at: http://www.acponline.org/advocacy/where_we_stand/policy/pcmh_neighbors.pdf

PCMH Neighbor Model (cont.) Defines concept of PCMH-N practices as practices that: Communicate, coordinate and integrate bidirectionally with PCMH Ensure appropriate and timely consultations and referrals Ensure effective flow of information; Address issues of responsibility in co-management situations; Support patient-centered care Support the PCMH practice as the provider of whole person primary care to the patient ACP-CSS Workgroup Policy Paper available at: http://www.acponline.org/advocacy/where_we_stand/policy/pcmh_neighbors.pdf

PCMH Neighbor Model: How Does It Work? Via Care Coordination Agreements, which promote better communication and care coordination by defining: Types of Interactions Pre-consultation exchange to expedite/ prioritize care Consultation /procedure Comanagement Shared care Principal care Responsibility for the elements of care Expectations for information exchange ACP-CSS Workgroup Policy Paper available at: http://www.acponline.org/advocacy/where_we_stand/policy/pcmh_neighbors.pdf

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: http://www.acponline.org/advocacy/where_we_stand/policy/pcmh_neighbors.pdf

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 ACOs Source: Premier Healthcare Alliance

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 oppose 2% Not sure 1% Oppose 7% Neither support nor oppose 12% Strongly support 46% Support 31% * Percentages may not be equal to 100 percent because of rounding. Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, July 2010.

Presentation Outline Joint Principles Specialty Care Connections PCMH Recognition programs Efforts to test the PCMH model PCMH Evaluations & Results

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 care Practice recognition provides purchasers (employers, government) and patients with prospective assurance that the practice has capabilities Recognized PCMHs also must be accountable for quality of care by reporting on evidence-based clinical and patient experience measures—provides retrospective assurance National Committee on Quality Assurance (NCQA) released the PPC-PCMH in January 2008; Revised version released in January 2011 Other entities are also developing or implementing PCMH recognition/accreditation processes – AAAHC, The Joint Commission, URAC

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 Home Address 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 Caregivers Engage Multiple Stakeholders in the Development and Implementation of the Program Align Standards, Elements, Characteristics, and/or Measures with Meaningful Use Requirements Identify Essential Standards, Elements, and Characteristics Joint Guidelines for PCMH Recognition and Accreditation Programs available at: http://www.acponline.org/running_practice/pcmh/understanding/guidelines_pcmh.pdf

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 Model Allow for Innovative Ideas Acknowledge Care Coordination within the Medical Neighborhood Clearly Identify PCMH Recognition or Accreditation Requirements for Training Programs Ensure Transparency in Program Structure and Scoring Apply Reasonable Documentation/Data Collection Requirements Conduct Evaluations of the Program’s Effectiveness and Implement Improvements Over Time Joint Guidelines for PCMH Recognition and Accreditation Programs available at: http://www.acponline.org/running_practice/pcmh/understanding/guidelines_pcmh.pdf

Presentation Outline Joint Principles Specialty Care Connections PCMH Recognition programs Efforts to test the PCMH model PCMH Evaluations & Results

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)

Initiatives to Advance Medical Homes in Medicaid/ CHIP = Identified to have a Medicaid and/or CHIP medical home initiative underway or under development Source: National Academy for State Health Policy (NASHP) State Map (http://nashp.org/med-home-map), March 2011

Medicare Multi-Payer Advanced Primary Care Initiative States = States participating in the Medicare Multi-Payer Advanced Primary Care Initiative Source: CMS, March 2011 (http://www.cms.gov/demoprojectsevalrpts/ md/itemdetail.asp?itemid=cms1230016)

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)

More Information on PCMH Demonstration Projects OR the PCPCC website: http://pcpcc.net/ See the ACP website: http://www.acponline.org/running_practice/pcmh/demonstrations/index.html

Presentation Outline Joint Principles Specialty Care Connections PCMH Recognition programs Efforts to test the PCMH model PCMH Evaluations & Results

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?

Community Implications - Results of PCMH Projects to Date (Integrated Systems) Group Health Cooperative of Puget Sound 29% reduction in ER visits; 16% reduction in hospital admissions $10 PMPM reduction in total costs Improvements in diabetes and heart disease care Greater staff satisfaction; less burnout; improved primary care recruitment and retention Geisinger Health System 18% reduction in hospital admissions 7 % reduction in total PMPM costs Improvements in preventive, diabetes, and heart disease care ROI greater than 2 to 1 Source: PCPCC Outcomes of Implementing PCMH Interventions (November 2010) - http://www.pcpcc.net/content/pcmh-outcome-evidence-quality

Community Implications –Results of PCMH Projects (Private Payer Sponsored) BCBS of South Carolina-Palmetto 36% fewer hospital days and 32% fewer ED visits among PCMH patients when compared with control patients 6.5% reduction in total medical costs for PCMH vs. control Metropolitan Health Networks-Humana (FL) Hospital days per 1000 customers dropped by 4.6 percent compared to an increase of 36 percent in the control group Hospital admissions per 1000 customers dropped by three percent, with readmissions running six percent below Medicare benchmarks Emergency room expense rose by only 4.5% for the PCMH group compared to an increase of 17.4% for the control group Source: PCPCC Outcomes of Implementing PCMH Interventions (November 2010) - http://www.pcpcc.net/content/pcmh-outcome-evidence-quality

Community Implications – Results of PCMH Projects (Medicaid Sponsored) Colorado Medicaid and SCHIP Median annual costs $785 vs $1000 in controls Reduction in ER visits & hospitalizations More 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) - http://www.pcpcc.net/content/pcmh-outcome-evidence-quality

PCPCC Evidence Summary More Results… PCPCC Evidence Summary And on the PCPCC website… www.pcpcc.net

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?

Thank You! Shari M. Erickson, MPH Director Regulatory and Insurer Affairs serickson@acponline.org 202-261-4551 Questions?