1. The Patient-Centered Medical Home: For Some or For All?*
07/16/96
The Patient-Centered Medical Home: For Some or For All?
Jeannette E. South-Paul, MD
Andrew W. Mathieson UPMC Professor and Chair, Family Medicine
University of Pittsburgh
STFM Annual Meeting – May 3, Denver *

2. The Primary Care Medical Home (PMCH)
Built upon the value of primary care in achieving better health outcomes, higher patient experience, and more efficient use of resources through continuous access to a personal physician who provides comprehensive and coordinated care for the large majority of their health care needs (IOM).

3. PCMH
A medical home can reduce or even eliminate racial and ethnic disparities in access and quality for insured persons
When adults have a medical home, their access to needed care, receipt of routine preventive screenings, and management of chronic conditions improve substantially
Beal AC, Doty MM, Hernandez SE, et al. Closing the divide: How Medical Homes Promote Equity in Health Care: Results from the Commonwealth Fund 2006 Health Care Quality Survey. The Commonwealth Fund, June 2007.

4. PMCH and Patient-Centeredness
Free choice of physician
Prompt appointments
Reduced waiting times
Care based on the best evidence of clinical effectiveness
Empowering patients to partner with their personal physician on decision-making
Care provided in a culturally and linguistically appropriate manner

5. In the US and Other Countries
Adults with a primary care physician rather than a specialist - 33% lower costs of care and 19% less likely to die.
Primary care physician supply - associated with improved health outcomes for cancer, heart disease, stroke, infant mortality, low birthweight, life expectancy, and self-rated care
In UK and US, each additional primary care physician per 10,000 persons is associated with a decrease in mortality rate of 3-10%
Starfield B, Shi L, Macinko J, et al. Improving chronic illness care: Translating evidence into action. Health Aff (Millwood).2001;20:64-78; Primary Care to Health Systemsd and Health. Milbank Quarterly 2005;83: ; Starfield, presentation to Commonwealth Fund, Primary Care Roundtable: Strengthening Adult Primary Care: Models and Policy Options, October 3, 2006.

6. In the United States…
An increase of just one primary care physician is associated with 1.44 fewer deaths per 10,000 persons
An orientation to primary care reduces socio-demographic and socio-economic disparities…such that African Americans with a primary care physician are less likely to die prematurely
Starfield B, Shi L, Macinko J, et al. Improving chronic illness care: Translating evidence into action. Health Aff (Millwood).2001;20:64-78; Primary Care to Health Systems and Health. Milbank Quarterly 2005;83: ; Starfield, presentation to Commonwealth Fund, Primary Care Roundtable: Strengthening Adult Primary Care: Models and Policy Options, October 3, 2006.

7. RAND-UC Berkeley Study
Rigorous evaluation of care according to PCMH principles
4000 patients with DM, CHF, RAD, and depression
Patients with DM had significant reductions in CVD risk
CHF patients had 35% fewer hospital days
RAD and DM patients were more likely to receive appropriate therapy
Higashi T, Wenger NS, Adams JL, et al. Relationship between number of medical conditions and quality of care. N Engl J Med 2007;356: ;

8. States in the US relying more on primary care have -
Lower Medicare spending – inpatient reimbursements and Part B payments
Lower resource inputs – hospital beds, ICU beds, total physician labor, primary care labor, and medical specialist labor
Lower utilization rates – physician visits, days in ICU, days in hospital, fewer patients seeing 10 + physicians
Better quality of care – fewer ICU deaths, higher composite quality score
Dartmouth Atlas of Health Care. Variation among States in the Management of Severe Illness, [accessed 4/8/09]

9. PPC - PCMH
NCQA’s Physician Practice Connections – Patient-Centered Medical Home – standards released January 2, 2008
Designed to identify physicians who deliver superior care using evidence-based standards

10. Aspects of Care Measured by PPC-PCMH (www.ncqa.org)
Access and Communication
Patient Tracking and Registry Functions
Care Management
Patient Self-Management Support
Electronic Prescribing
Test Tracking
Referral Tracking
Performance Reporting and Improvement
Advanced Electronic Communications

11. Crossing the Quality Chasm: A New Health System for the 21st Century
Six major aims for a quality health care system –
Safe
Effective
Patient-centered
Timely
Efficient
Equitable
2001 IOM Report

12. Crossing the Quality Chasm: 10 Simple Rules for the 21st Century Health Care System
Care based on continuous healing relationships
Customization based on patient needs and values
The patient as the source of control
Shared knowledge and the free flow of information
Evidence-based decision making

13. Crossing the Quality Chasm: 10 Simple Rules for the 21st Century Health Care System
Safety as a system property
The need for transparency
Anticipation of needs
Continuous decrease in waste
Cooperation among clinicians

14. Medicare Disincentives to Care Coordination
Payment system rewards physicians for increasing volume of visits and procedure
Payment structure that does not provide incentives for physicians to coordinate care
No mechanism for physicians to share in the savings that physician-guided care coordination activities generate in other areas of Medicare
The flawed sustainable growth rate (SGR) formula
ACP –

15. Limitations of the PCMH Model
Uses traditional insurance metrics
Rewards clinicians that manage those metrics
Does not establish link between metrics and health
Groups patients artificially within practices – by insurer or by disease
Ignores cultural determinants
Does not describe a new model of managing care – culturally proficient, practice-based care manager

16. A Missing Link to the Universal PCMH
A different way of thinking

17. Object Lesson – Greg Mortenson

18. *
07/16/96
Culture
“Culture is not an optional factor that only influences health and illness; it is prerequisite for all meaningful human experience, including that of being ill… among all people, not just members of “exotic” cultures… healers as well as patients are dwellers in cultures.” *

20. American Indian/Alaska Native
Health Insurance Coverage of the Nonelderly Population by Race/Ethnicity, 2002
Uninsured
Medicaid and Other Public
Individual
Employer
Voiceover:
People of color are more likely to be uninsured than are whites, largely reflecting lower rates of employer-based coverage.
The lack of health insurance affects an individual's ability to obtain care and has consequences for health and financial well-being.
Latinos are the most likely to be uninsured, with over a third (34%) of nonelderly Latinos uninsured in 2002.
Medicaid is an especially important source of coverage for people or color, providing health coverage for at least 1 in 5 nonelderly Latinos, African Americans, and American Indians/Alaska Natives. In comparison, about 1 in 10 Asian/Pacific Islanders and whites are covered by Medicaid.
White
(Non-Latino)
African
American
(Non-Latino)
Asian
Only
American Indian/Alaska Native
Latino
NOTE: “Other Public” includes Medicare and military-related coverage; two or more races not shown.
SOURCE: Kaiser Commission on Medicaid and the Uninsured, Health Insurance Coverage in America: 2001 Data Update, 2003.

21. No Usual Source of Health Care: Adults 18-64, by Race/Ethnicity,1993-1994 and 2000-2001
Percent without a usual source of care
Voiceover:
An estimated 40 million Americans lack a regular source of medical care.
People of color are generally in poorer health than whites, yet data in Figure 10 show that 31% of Latinos and 19% of Asians lacked a regular source of medical care, compared with 14% of whites.
Since 1994, the percent of each racial/ethnic group without a regular source of care has declined among all groups except Latinos.
White (Non-Latino)
Latino
African American (Non-Latino)
Asian Only
American Indian/Alaska Native
DATA: National Center for Health Statistics, National Health Interview Survey.
SOURCE: Health, United States, 2003, Table 76.

22. Determinants of Health
Health Care
Genetic
This slide should illustrate that health care does determine a component of one’s health, and this is where docs can make a difference.
Environment
Behavior
Adapted from McGinnis et al., Health Affairs 2002

23. IOM Report, 2002: Assessing the Quality of Minority Health Care
“Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases, which is unacceptable.”
-- Alan Nelson, former president of the AMA and chair of the committee that wrote the Institute of Medicine report, Unequal Treatment: Confronting Racial and Disparities in Health Care
The future health of America as a whole will be influenced substantially by our success in improving the health of ethnic and racial minorities groups.
People of color (Latinos, African Americans, Asian/Pacific Islanders, and American Indian/Alaska Natives) make up nearly a third of the U.S. population.
By the year 2050, the U.S. Census estimates that these groups combined will make up nearly half of the U.S. population.
Groups currently experiencing poorer health status are expected to grow as a proportion of the total U.S. population.

24. Mortality Ratios, by Age and Race/Ethnicity, 2000
African American (Non-Latino)
American Indian
White (Non-Latino)
Latino
Asian Only
Voiceover:
We also can learn about the health of a population group by looking at mortality rates.
On average, Latinos, African Americans, American Indians and whites have higher mortality rates than Asian/Pacific Islanders at each stage of the lifespan.
However, aggregate national data for a population group mask the higher mortality rates of racial/ethnic subpopulations such as, Native Hawaiians, or Puerto Ricans.
In general, major causes of death are similar across racial/ethnic groups – heart disease and cancer are leading causes of death for middle and older age groups and accidents are a leading cause of death for younger age groups.
There are two exceptions of note: In 2000, HIV was still the leading cause of death for African Americans aged 25 to 44 and liver disease was the 2nd leading cause of death for American Indian/Alaska Natives
Age in Years
NOTE: These data compare the mortality rate of each racial/ethnic group to that of Asian/
Pacific Islanders, the group with the lowest mortality rates at each age.DATA: National Center f
or Health Statistics, National Vital Statistics (Vol. 50, No. 15, September 16, 2002.).
SOURCE: Kaiser Family Foundation, Key Facts: Race, Ethnicity and Medical Care, 2003, Figure 7.

25. Higher Death Rates African Americans
CVD; Breast, Prostate, & Lung CA; DM; Infant Mortality; HIV/AIDS
Hispanic Americans
DM; Uncontrolled Hypertension; HIV/AIDS
Asian/Pacific Islander Americans
Tuberculosis; Stroke; Cervical Cancer
American Indians/Alaska Natives
DM; Infant Mortality

26. Cancer Disparities Data collected by NCIs SEER Program
Prevalence of major cancer risk factors and cancer screening (National Health Interview Survey)
For all cancer sites combined, residents of poorer counties have 13% higher death rates from cancer in men and 3% higher rates in women compared with more affluent counties
Ward E, Jemal A, Cokkinides V et al. Cancer disparities by race/ethnicity and socioeconomic status. CA Clancer J Clin 2004;54:78

27. Cancer Disparities Data collected by NCIs SEER Program
Five year survival for all cancers combined is 10% lower among persons who live in poorer rather than affluent census tracts
Even after accounting for poverty, there is lower five-year survival for African Americans, American Indians and Asian Pacific Americans than for non-Hispanic whites
Ward E, Jemal A, Cokkinides V et al. Cancer disparities by race/ethnicity and socioeconomic status. CA Clancer J Clin 2004;54:78

28. Cancer Among Hispanics
Hispanics living in neighborhoods with higher density of Hispanic populations were more likely to be diagnosed with late-stage breast, cervical, or colorectal cancer, and to have a larger tumor size of breast cancer
Reyes-Ortiz CA, Eschbach K, Zhang DD, Goodwin JS. Neighborhood composition and cancer among Hispanics: tumor stage and size at time of diagnosis. Cancer Epidemiology Biomarkers & Prevention 2008;17(11):

29. Differential Treatment by Race/ Ethnicity and Gender*
07/16/96
Diagnosis and treatment of coronary artery disease
Prescription of secondary prevention measures for CAD
Treatment of osteoporotic fractures in women and subsequent preventive counseling
Schulman KA et al. N Engl J Med 1999;340:618-26
Leape LL et al. Ann Int Med 1999;130(3):189-92,231-3
Circulation and JBJS, 2000 *

30. Race, gender, and partnership in the patient-physician relationship*
Race, gender, and partnership in the patient-physician relationship
07/16/96
Telephone survey Nov 96-Jun 98, n=1816, years; 43% white, 45% Af Am
Physician sample , n=64, 63% male, 56% white, 25% Af Amer
Patients rated their physicians’ participatory decision-making style
Af Am patients rate their visits with physicians as less participatory than whites
Cooper-Patrick L, Gallo JJ et al. JAMA 1999;282: *

31. Minorities Face Greater Difficulty in Communicating with Physicians*
07/16/96
Minorities Face Greater Difficulty in Communicating with Physicians
Percent of adults with one or more communication problems*
Base: Adults with health care visit in past two years.
*Problems include understanding doctor, feeling doctor listened, had questions
but did not ask.
Source: The Commonwealth Fund 2001 Health Care Quality Survey. *

32. Relationship Between Physicians and Quality of Care
Large differences among states
Not correlated with absolute numbers of physicians or distribution of physician specialties alone
Depends on socioeconomic or cultural factors not defined
Influenced by geography
Musgrove P. Primary/specialty care: an author responds. Health Affairs Mar/Apr 2009;28(2):594-5
Skinner JS. Geographical analysis:an author responds. Health Affairs Mar/Apr 2009;28(2):595-6.

33. Quality Focus
The issue is the impact of health services on health, not on the quality of care
Chen L, et al. Human resources for health: overcoming the crisis. Lancet 2004;364(9449):
Consistent evidence that what really matters in improving population health is not the number of physicians, but what those physicians do
Starfield B, Shi L, Macinko J. Physicians and quality: answering the wrong question. Health Affairs Mar/Apr 2009;28(2):596

34. Primary Care
Studies examining health outcomes of people whose regular source of care is a primary care physician note that the stronger the achievement of primary care functions, the better the outcomes
Essential primary care functions – person-focused, not disease-focused; care over time; comprehensiveness of services; coordination of care
Starfield B, Shi L, Macinko J. Physicians and quality: answering the wrong question. Health Affairs Mar/Apr 2009;28(2):596

36. PCMH – For Some or for All?
Will depend on mandated goals –
Geographic distribution; cultural mix; comprehensiveness of services provided
Will depend on economic structure/incentives – Balanced reimbursement for all patients for same procedures/services
Will require availability of primary care physicians
Equal levels of care providers for all patients

37. PCMH – For Some or for All?
Will depend on mandated goals –
Geographic distribution; cultural mix; comprehensiveness of services provided
Will depend on economic structure/incentives
Balanced reimbursement for all patients for same procedures/services
Will require availability of primary care physicians
Equal levels of care providers for all patients
Will depend on us!!

38. Barriers to a PCMH for All
Commitment to the most vulnerable
Leadership
Resource allocation
Focus from the Heart

39. Commitment to the Most Vulnerable
Know your community
Know your allies
Know your enemies
Don’t give up!!!

40. Leadership
Organizational diagnosis
Hard work
Creativity
Negotiation skills

41. Resource Allocation
Opportunity investment – out of pocket
Institutional funds
Foundation funds
Community outreach and resources

42. Commitment from the Heart
Internal focus
Support system
Sustaining personal health – spiritual, physical, emotional, social

43. Wisdom of Solomon
About minding what is inside the heart…
“Above all else, guard your heart, for it is the wellspring of life..” Proverbs 4:23

44. The Tribal Wisdom of the Dakota Indians, passed on from one generation to the next, says that when you discover that you are riding a dead horse, the best strategy is to dismount.

45. :
But in modern business including educational institutions, and government, because heavy investment factors are taken into consideration, other strategies are often tried with dead horses, such as the following

46. Buying a stronger whip
Changing riders
Threatening the horse with termination
Appointing a committee to study the horse
Arranging to visit other sites to see how they ride dead horses

47. Lowering the standards so dead horses can be included
Reclassifying the dead horse as “living-impaired”
Hiring outside contractors to ride the dead horse
Harnessing several dead horses together to increase speed

48. Providing additional funding and/or training to increase the dead horse’s performance
Doing a productivity study to see if lighter riders would improve the dead horse’s performance
Declaring that the dead horse carries lower overhead and the4refore contributes more to the bottom line than some other horses
Rewriting the expected performance requirements for all horses.

49. And as a final strategy …
Promoting the dead horse to a supervisory position!

50. *
07/16/96
Educating for the PCMH
Monitor changing demographics and community needs of the community
Involve community representatives in planning quality improvement efforts
Make changes in the system to address the specific needs of the organization and the community
Be willing to negotiate and compromise to achieve improved and realistic outcomes
Imbed all things community in the curriculum early and often…and
DO NOT ALLOW OUR INSTITUTIONS TO
FORGET THE OTHER AMERICA! *

51. Effective, Culturally-Proficient PCMH
Consistently monitor cultural data
Race, ethnicity, SES, family structure, homelessness, educational level, literacy
Demographics of the practice - # uninsured, LEP, transportation
Psychosocial support
Integrate physical and behavioral health
Utilize faith-based resources

52. *
07/16/96
Questions *