1. Medicaid Medical Homes: What’s Working and What’s Next
Session Overview: Patient-centered medical homes (PCMHs) and health homes have become two predominant models for transforming primary care from volume to value in Medicaid. As policymakers reflect on these models, it’s important to take a closer look at what we know is working and what’s not, and how that informs the future of primary care transformation. Participants will hear from leading state and national experts about the state of PCMH in Medicaid and explore the future of this model in value-based transformation.
Moderator: Marci Nielsen PhD, MPH, President & CEO, Patient-Centered Primary Care Collaborative
Mark Friedberg, MD, MPP, Senior Natural Scientist, Director, RAND Boston
Dawn Stehle, Director, Division of Medical Services, Arkansas Department of Human Services
Marie Zimmerman, Medicaid Director, Minnesota Department of Human Services

2. US Health Expenditures

3. PCMH MODEL/FRAMEWORK
• Patient-centered: The PCMH supports patients in learning to manage and organize their own care based on their preferences, and ensures that patients, families, and caregivers are fully included in the development of their care plans. It also encourages them to participate in quality improvement, research, and health policy efforts.
• Comprehensive: The PCMH offers whole-person care from a team of providers that is accountable for the patient’s physical and behavioral/mental health needs, including prevention and wellness, acute care, and chronic care.
• Coordinated: The PCMH ensures that care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services, and long-term care supports.
• Accessible: The PCMH delivers accessible services with shorter waiting times, enhanced in-person hours, 24/7 electronic or telephone access, and alternative methods of communication through health information technology (HIT).
• Committed to Quality and Safety: The PCMH demonstrates commitment to quality improvement and the use of data and health information technology (HIT) and other tools to assist patients and families in making informed decisions about their health.
While most PCMH primary care practices strive to incorporate all of the attributes, the medical home is not a “one size fits all” framework. Each practice implements the attributes based on its own unique characteristics, such as: the size of the practice; the location (i.e. urban versus rural setting); the composition (solo/small practice, mid-size primary care practice, large multi-specialty practice, academic affiliated practice, etc.); the patient population it serves (health status, other social & economic characteristics); whether financial or performance incentives are provided, etc.
Many PCMH practices – but certainly not all – choose to become “certified” or “recognized” by outside entity (national accrediting body, health plan, state agency). PCMH recognition programs vary in the amount of required documentation, application costs and overall efforts. This can enhance the practices’ ability to obtain increased reimbursement, if there are payers in their marketplace that offer it.

4. PATIENT-CENTERED PRIMARY CARE
Hospital
Home
Health
Health IT $
Patient-Centered Medical Home 
Public Health
Employers
Schools
Faith-Based Organizations
Community Centers
Pharmacy
Oral Health
Mental
Health
Specialty & Subspecialty
A primary care patient-centered medical home is the heart of health care delivery AND community health. This is especially true for high risk or complex patients, such as those with chronic diseases, mental and behavioral health issues, and other special needs. Environmental factors such as socioeconomic status, employment, access to healthy foods, transportation, and physical environment are important predictors of health because for individuals and families of low income, access to care, coordination, and health literacy can make attaining good health more challenging.
The medical neighborhood is defined by the PCPCC as a clinical-community partnership that includes the medical and social supports necessary to enhance health, with the PCMH serving as the patient’s primary “hub” and coordinator of health care delivery.
The goals of a high-functioning PCMH include collaborating with these various “medical neighbors” to encourage the flow of information across and between clinicians and patients, to include specialists, hospitals, home health, long term care, and other clinical providers. In addition, non-clinical partners like community centers, faith-based organizations, schools, employers, public health agencies, YMCAs, and nutrition providers for home-bound seniors, such as Meals on Wheels. Together these organizations can actively promote care coordination, fitness, healthy behaviors, proper nutrition, as well as healthy environments and workplaces. AHRQ articulates that a successful medical neighborhood will “focus on meeting the needs of the individual patient, but also incorporate aspects of population health and overall community health needs.” $
Skilled Nursing Facility
Health IT

5. PCMH EXPANDING RAPIDLY: BUT STILL AN EARLY INNOVATION
The patient-centered medical home or PCMH (sometimes referred to as medical home, or advanced primary care) is a fairly recent innovation in care delivery designed to improve patient experience, improve population health, and reduce cost of care. Although it’s origins date back to 1967 (in pediatrics), the medical home concept has grown over the past decade, with nearly 500 public and private sector PCMH initiatives being tracked across the US (

6. MEDICAID & MEDICAL HOME ACTIVITY

8. GROWING BODY OF PCMH EVIDENCE
2015 Annual Evidence Report:
What we studied & what we learned
Paying for Value
Where delivery reform meets payment reform
What’s Next?

9. ROI IS KEY (n1 = Improvement in measure/n2 = Measure assessed by study)

10. KEY FINDING Controlling Costs by providing the Right Care
POSITIVE CONSISTENT TRENDS:
By providing the right primary care “upstream,” we change how care is used “downstream”
Consistent reductions in high-cost (and many times avoidable) care, such as: emergency department (ED) use and hospitalization, etc
Cost savings evident – but assessment of total cost of care required (while assessing quality, health outcomes, patient engagement, & provider satisfaction)

11. KEY FINDING Aligning Payment and Performance
BEST OUTCOMES FOR MULTI-PAYER EFFORTS:
Most impressive cost & utilization outcomes among multi-payer collaboratives with incentives/performance measures linked to quality, utilization, patient engagement, or cost savings … more mature PCMHs had better outcomes
No single best payment model emerged, but extended beyond fee-for-service

12. KEY FINDING Assessing and Promoting Value
BETTER MEASURES & DEFINITIONS:
Variation across study measures -- and PCMH initiatives – make for challenging evaluations and expectations (patients, providers, payers)

14. COMPREHENSIVE PRIMARY CARE (CPC) INITIATIVE

15. PCPCC RECOMMENDATIONS TO PROPOSED RULE
Revise the implementation timeline
CMS moved to the “pick your pace” framework
Expand recognition of patient-centered medical homes 
CMS added state-based, regional or state programs, private payers, or entities that administer patient-centered medical home accreditation to at least 500 practices
Streamline quality measurement
CMS reduced/simplified quality measure reporting
Acknowledge the challenges of solo and small practices and provide greater support for them
CMS changed the low volume threshold & increased technical support aimed at small/solo providers
Strengthen beneficiary engagement
Various CPIA activities aimed at beneficiaries
Provide multiple pathways for medical homes to qualify as advanced alternative payment models
Medical homes subject to unique nominal risk requirements; CPC+