1. Maine Multi-Payer Pilot Patient Centered Medical Home Model November 2008 Lisa M. Letourneau MD, MPH A Collaborative Effort of the Maine Quality Forum, Quality Counts, & the Maine Health Management Coalition

2. Objectives Review history, principles of Patient Centered Medical Home model Describe development, goals for Maine Multi-payor Pilot of PCMH model Outline key steps for successful PCMH pilot implementation in Maine

3. The Challlenge

4. The Facts More (and more) U.S. health care spending… Why Not the Best? Results from the National Scorecard on U.S. Health System Performance 2008, Commonwealth Fund

5. Does not equal better outcomes (and sometimes worse)

6. The Facts *Rank based on patient satisfaction, expenditures per person, 14 health indicators, and medications per person in Australia, Belgium, Canada, Denmark, Finland, Germany, Netherlands, Spain, Sweden, United Kingdom, United States More primary care services are associated with better outcomes

7. Defining Primary Care “The provision of integrated, accessible health care services by clinicians who are accountable for addressing the large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” Institute of Medicine: Primary Care: America’s Health in a New Era, Washington DC: National Academy Press, 1996

8. What We Want from Primary Care A relationship with our providers that crosses settings, time, & place Caring, compassionate interactions Coordination & integration of care across providers Ability to access care 24/7 – when & where we need it Time, time, time…

9. What Do We Get? The 15 minute visit!

10. Why? Follow the Money! What we want: Relationship with our providers Caring, compassionate interactions Coordination & integration of care Ability to access care 24/7 Time, time, time… What we pay for: Visits Tests Procedures Vs.

11. The Stalemate that Blocks Change Providers unable to transform practice without viable & sustainable payment for desired services Employers & payers unwilling to pay for desired services unless primary care demonstrates value AND create potential to save money BUTBUT

12. The Result: The Current Primary Care Home

13. The Medical Home: A Model for Change! Providers transform practice, create value with viable & sustainable payment for desired services = Practice Transformation Employers & payers pay for desired services because primary care demonstrates value AND saves money = Payment Reform ANDAND

14. Breaking the Stalemate PCMH recognizes need, supports BOTH… Practice Transformation to give us what we want… Relationship with our providers Caring, compassionate interactions Coordination & integration of care Ability to access care 24/7 Payment Reform to pay providers for … Time for caring, compassionate interactions Coordination & integration of care, care management Access to care 24/7 Information systems needed to integrate care Population health management +

15. Defining Medical Home “A medical home is not a building, house, or hospital, but rather an approach to providing comprehensive primary care. A medical home is defined as primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.” American Academy Pediatrics

16. Medical Home - Background Concept first introduced by AAP in 1964 – children with special health care needs AAFP “New Model” of family medicine – 2004 Tested in “National Demonstration Project” (TransforMED) - 2006-2008 AAP, ACP, AAFP, AOA together draft “PCMH Joint Principles” - 2007 Partner with health plans, employers, CMS in “Patient Centered Primary Care Collaborative” Emergence of multi-stakeholder pilots across country

17. AAFP-AAP-ACP-AOA PCMH Joint Principles 1.Every patient has a personal physician 2.Care is provided by a physician-directed team who collectively care for patient 3.Personal physician is responsible for providing all patient’s needs, or arranging for services to be provided by others 4.Care is coordinated and integrated across all aspects of healthcare system

18. AAFP-AAP-ACP-AOA PCMH Joint Principles 5.Quality and safety are hallmarks of PCMH  Evidence-based guidelines and tools guide care  Practice regularly assess its quality of care 6.Patients are offered enhanced access to care (e.g. expanded hours, enhanced communication options) 7.Payment appropriate recognizes added value of PCMH

19. PCMH-Emergence of Multi-Payer Pilots Multi-Payer pilot discussions/activity RI Identified pilot activity No identified pilot activity

20. Maine PCMH Pilot Leadership Quality Counts Maine Quality Forum Maine Health Management Coalition

21. Maine Multi-Payer PCMH Pilot Led by neutral multi-stakeholder collaborative – MQF, QC, MHMC, open to all interested Participation of 4 major private payers & MaineCare Established mission & vision, guiding principles for Maine PCMH model Pending funding resources…, –Will select 10-20 pilot practices across state –Will provide shared resources to support practice transformation –Will develop framework to promote shared learning across & beyond pilot practices

22. Maine Multi-Payer Pilot Status PCMH Working Group – work to date: 1.Secured initial funds for planning process 2.Est’d Maine PCMH model thru mission & vision, Maine PCMH Guiding Principles 3.Est’d criteria, threshold for practice site participation 3.Dev’d initial framework for pilot evaluation 4.Dev’ing specific expectations practice participation (MOA) 5.Dev’ing criteria, method for selecting practice pilots

23. Maine Multi-Payer Pilot Status PCMH Working Group – work in progress… 6. More fully identify outcome measures, evaluation plan 7. Dev plan for supporting practice transformation 8. Conduct outreach, communication to key stakeholders, including all PCP practices 9. Identify additional resources to support implementation

24. Maine Multi-Payer – Payment Model MHMC-convened Physician Payment Reform Comm Dev’d principles for payment model Has kept all private payers & MaineCare at table Proposed (9/24) 3-component payment model  Prospective (pmpm) care management payment  Ongoing FFS payments, possibly with additional payments for previously non-reimbursed services  Performance Payment for meeting quality & total cost savings targets – shared savings model

25. Maine PCMH Pilot: What Practices Need to Know Criteria for application –Maine primary care practice –Completed MHIQ c/w Level I NCQA PPC-PCMH –Minimum panel size (TBD) Agreements for participating practices (MOA) –Identified leadership, full participation of practice team –Participation in PCMH Learning Collaborative, QI coaching –Tracking, submission of clinical outcomes data –Agreement to achieve “Core Commitments” within 12 mos of start

26. Maine PCMH Pilot Practice “Core Commitments” (DRAFT!) 1.Demonstrated physician leadership 2.Team-based approach 3.Practice-integrated care management 4.Same-day access 5.Behavioral-physical health integration 6.Inclusion of patients & families 7.Connection to community / local HMP 8.Commitment to waste reduction

27. PCMH & Opportunities for Improving Safe Prescribing Medical home as focal point for coordinating prescribing across providers EMR / registry support Nurse care coordination PCMH Learning Collaborative to offer support on safe prescribing Ultimately… TIME!!

28. Maine Pilot - Issues TBD Will all employers, payers engage in new payment model? Will new payment be enough to support true practice transformation? What criteria for pilot site selection? How to engage specialists, hospitals in shared goals, shared cost savings? How to engage patients in new partnership?

29. Needed to Move Forward Engagement, leadership, and dialog among key stakeholders –Consumers –Physicians, NPs, provider organizations/PHO’s, medical groups –Payers – private & public –Employers –Public health Culture change to create, sustain transformative change Commitment to collaboration!

30. PCMH Creating Hope for a Better System With thanks to Dr. Tom Bodenheimer, Dept. Family & Community Med, UCSF