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

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

3. 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: demonstrations/jointprinc_05_17.pdf (March 2007)

4. “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

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

6. 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:

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 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).

8. 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:

9. 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:

10. 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:

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 ACOs
Source: 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 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.

14. Presentation Outline Joint Principles Specialty Care Connections
PCMH Recognition programs
Efforts to test the PCMH model
PCMH 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 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

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 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:

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 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:

18. Presentation Outline Joint Principles Specialty Care Connections
PCMH Recognition programs
Efforts to test the PCMH model
PCMH 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 development
Source: National Academy for State Health Policy (NASHP) State Map ( March 2011

21. Medicare Multi-Payer Advanced Primary Care Initiative States
= States participating in the Medicare Multi-Payer Advanced Primary Care Initiative
Source: CMS, March 2011 ( 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 programs
Efforts to test the PCMH model
PCMH 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 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) -

27. 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) -

28. 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) -

29. PCPCC Evidence Summary
More Results…
PCPCC Evidence Summary
And 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 Affairs
Questions?