1. Edwina Rogers Executive Director Patient Centered Primary Care Collaborative 601 Thirteenth St., NW, Suite 400 North Washington, D.C. 20005 Direct: 202.724.3331 Mobile: 202.674.7800 erogers@pcpcc.net Patient Centered Primary Care Collaborative and the National Patient Centered Medical Home Movement 1

2. Overview of Activity 27 Multi-stakeholder and other Pilots in 18 States 44 States and the District of Columbia Have Passed over 330 Laws and/or Have PCMH Activity Medicaid and Medicare Activity 2

3. 3 Blue Cross Blue Shield Plan Pilots (As of March 2010) Pilots in planning phase for 2010 implementation Multi-Stakeholder demonstration Pilot activity in early stages of development Pilots in progress

4. There are 37 States Working to Advance Medical Homes for Medicaid or CHIP Beneficiaries AK NHNH MA ME NJ CT RIRI DE VTVT NYNY DC MDMD NC PA VA WVWV FL GA SC KY ININ OH MIMI TNTN MS AL MO ILIL IAIA MNMN WIWI LA AR OK TXTX KS NE NDND SD HIHI MT WYWY UT CO AZ NMNM IDID OR WAWA NVNV CA States with at least one effort that met criteria for analysis SOURCE: NASHP analysis

5. Patient-Centered Medical Home Overview of Pilot Activity and Planning Discussions RI Multi-Payer pilot discussions/activity Identified pilot activity No identified pilot activity – 5 States 5

6. PCPCC Membership and Activity Overview  National Convener on the PMCH  Legislative and Regulatory Advocacy  Develop PCMH Policy More than 700 members 54 Executive Committee Members 20 Advisory Board Members 5 Centers 7 Task Forces 3 Annual Conferences & Summits Monthly Calls (National PCMH Movement Briefings, CMD, CPPI, CCE) Bi-Weekly Calls (CEE, CeHIA) National Weekly Call (Thursday, 11AM EDT) Phone number: 712.432.3900 Passcode: 471334 Host Regular Webinars 6

7. The Patient-Centered Primary Care Collaborative ACP Providers 333,000 primary care Purchasers – Most of the Fortune 500 Payers Patients AAP AAFP AOA ABIM ACC ACOI AHI IBM Ohio General Electric FedEx Microsoft Dow Merck & Co. Business Coalitions BCBSA United Aetna CIGNA Humana WellPoint Kaiser Permanente AARP AFL-CIO National Consumers League SEIU Foundation for Informed Decision Making Examples of Broad Stakeholder Support & Participation The Patient-Centered Medical Home 80 Million lives 7 Geisinger Iowa

8. Patient Centered Primary Care Collaborative Five ‘Centers’ - Over 770 volunteer members Center for Multi-Stakeholder Demonstration: Identify community-based pilot sites in order to test and evaluate the concept; offer hands-on technical assistance, share best practices, and identify funding sources to advance adoption.  Center to Promote Public Payer Implementation: Assist state Medicaid agencies and other public payers as they implement and refine programs to embed the Patient Centered Medical Home model by offering technical assistance; sharing best practices and giving guidance on the development of successful funding models.  Center for Employer Engagement: Create standards and buying criteria to serve as a guide and tool for large and small employers/purchasers in order to build the market demand for adoption of the Medical Home model.  Center for eHealth Information Adoption and Exchange: Evaluate use and application of information technology to support and enable the development and broad adoption of information technology in private practice and among community practitioners.  Center for Consumer Engagement: Engage the consumer in awareness activities through three ways: day-to-day operations, messaging and pilots. The center will continue the use of “Patient Centered Medical Home”, but focus on how the concept and its components are communicated to the public and partner with large consumer groups to capitalize on their visibility and existing efforts. 9 8

9. PCPCC Center and Task Force Recent Deliverables  Value Based Insurance Design Report  Payment Reform Task Force Report  PCMH Transformation Resource Guide  Medication Management Guide  Emmi Solutions PCMH Video (soon to be available in Spanish)  Pilot Activity Tracking from CMD website  Letters to Congress  Letters Regarding Meaningful Use 9

10. History of the Medical Home Concept  The first known documentation of the term “medical home” Standards of Child Health Care, AAP in 1967 by the AAP Council on Pediatric Practice -- “medical home -- one central source of a child’s pediatric records” History of the Medical Home Concept Calvin Sia, Thomas F. Tonniges, Elizabeth Osterhus and Sharon Taba Pediatrics 2004;113;1473- 1478  Patient Centered – IOM  I would strongly urge the adoption of the Danish model of the Patient Centered Medical Home -- Karen Davis Commonwealth Fund  2010 Medical Home Wikipedia page: http://en.wikipedia.org/wiki/Medical_home 10

11. JOINT PRINCIPLES OF THE PCMH (FEBRUARY 2007) The following principles were written and agreed upon by the four Primary Care Physician Organizations – the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association. Principles: Ongoing relationship with personal physician Physician directed medical practice Whole person orientation Coordinated care across the health system Quality and safety Enhanced access to care Payment recognizes the value added 11

12. ENDORSEMENTS The PCMH Joint Principles have received endorsements from 18 specialty health care organizations : The American Academy of Chest Physicians The American Academy of Hospice and Palliative Medicine The American Academy of Neurology The American College of Cardiology The American College of Osteopathic Family Physicians The American College of Osteopathic Internists The American Geriatrics Society The American Medical Directors Association The American Society of Addiction Medicine The American Society of Clinical Oncology The Society for Adolescent Medicine The Society of Critical Care Medicine The Society of General Internal Medicine American Medical Association Association of Professors of Medicine Association of Program Directors in Internal Medicine Clerkship Directors in Internal Medicine Infectious Diseases Society of Medicine 12

13. Superb Access to Care Patients can easily make appointments and select the day and time. Waiting times are short. eMail and telephone consultations are offered. Off-hour service is available. Patient Engagement in Care Patients have the option of being informed and engaged partners in their care. Practices provide information on treatment plans, preventative and follow-up care reminders, access to medical records, assistance with self-care, and counseling. Clinical Information Systems These systems support high-quality care, practice-based learning, and quality improvement. Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments. Care Coordination Specialist care is coordinated, and systems are in place to prevent errors that occur when multiple physicians are involved. Follow-up and support is provided. Team Care Integrated and coordinated team care depends on a free flow of communication among physicians, nurses, case managers and other health professionals (including BH specialists). Duplication of tests and procedures is avoided. Patient Feedback Patients routinely provide feedback to doctors; practices take advantage of low- cost, internet-based patient surveys to learn from patients and inform treatment plans. Publically available information Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs. 8 Source: Health2 Resources 9.30.08 Defining the Medical Home 13

14. Accountable Care Organizations 14 Source: Premier Healthcare Alliance

15. PCPCC Payment Model May 2007 Care Coordination Office Visits Performance Blended Hybrid Payment Model (expanding upon the existing fee- for-service paradigm) Key physician and practice accountabilities/ value added services and tools Proactively work to keep patients healthy and manage existing illness or conditions Coordinate patient care among an organized team of health care professionals Utilize systems at the practice level to achieve higher quality of care and better outcomes Focus on whole person care for their patients (including behavioral health) Performance Standards Incentives 16 15

16. At least 14 Independent Evaluations in 11 States... And Growing RI CMS will select 8 states for the Medicare Medical Home Demonstration 16

17. Several PCMH Evaluations Underway… The evaluations are examining a breadth of demonstrations: From one payer to multi-payer pilots Involve anywhere from 5-70 primary care practices with 28-250 clinicians Include 27,000 -- 1,000,000 beneficiaries Many include safety net centers, pediatric sites and Medicaid as a payer Variety of payment models (hybrid, PMPM, annual comprehensive PC fee) All of these independent evaluations have comparison groups 17

18. PCMH Evaluations (cont.) 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? 18

19. Community Implications - Published Results of PCMH Projects to Date Group Health Cooperative of Puget Sound 29% reduction in ER visits; 11% reduction in ambulatory care sensitive admissions Improvements in diabetes and heart disease care Cost neutral after 1 year Geisinger Health System 14% decrease in hospital admissions Improvements in diabetes and heart disease care 9 % reduction in costs ROI greater than 2 to 1 Source: PCPCC Pilot Guide, 2009 19

20. Community Implications – Published Results of PCMH Projects (cont.) Colorado Medicaid & SCHIP Median annual costs $785 vs $1000 Reduction in ER visits & hospitalizations More well-child visits (72% vs 27%) Lower median costs for children with chronic conditions ($2,275 versus $3,404) HealthPartners Medical Group (MN) 39% decrease in ER visits 24% decrease in hospital admissions Better diabetes and cardiac care Reduced costs Source: PCPCC Pilot Guide, 2009 20

21. Community Implications – Published Results of PCMH Projects (cont.) Metcare of Florida/Humana PCMH Program Started in November 2008 & Concluded in October 2009 Studied the impact of the PCMH model in a Medicare Advantage (MA) capitated group 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 Metcare group compared to an increase of 17.4% for the control group Overall medical expense for the Metcare group rose by only 5.2 percent compared to 26.3 percent increase for the control group Preventive breast and colorectal cancer screening was 13.3 percent and 6.3 percent higher respectively, compared to the control group Average LDL cholesterol levels dropped by 1.8 percent, and customers with levels below 100 (a target level) rose by 4.0 percent Ninety-four percent of diabetic patients had an A1C level of less than nine percent Source: Metcare Press Release, February 23, 2010 21

22. Community Implications – Preliminary Findings of Other PCMH Projects (cont.) National Naval Medical Center Medical Home Program (Bethesda, MD) Started 4/1/08 – ongoing 1 IM practice; 35,000 covered lives PCM continuity of care increase of 33% 20.8% decrease in network ER visits per 100 enrollees 39.5% decrease in total annual ER visits per 100 enrollees 40.4% decrease in total specialty care visits per 100 enrollees Source: PCPCC Pilot Guide, 2009 22

23. Community Implications – Preliminary Findings of Other PCMH Projects (cont.) Rhode Island Chronic Care Sustainability Initiative Started 10/1/08; 2-3 years 5 IM and FP practices; 28,000 covered lives Multi-stakeholder First nine months of program (all sites combined): Diabetes patients with a documented hemoglobin A1c improved from 64% to 72% Diabetes patients with BP <130/80 improved from 18% to 30% CAD patients on Beta blocker improved from 40% to 65% Smokers with documented advice to quit improved from 14% to 35% Source: PCPCC Pilot Guide, 2009 23

24. NC Savings (FY04) Category of ServiceEstimated Savings from Benchmark Inpatient$142,085,680 Outpatient$51,865,028 Emergency Room$25,944,553 Primary Care, Specialist$45,498,709 Pharmacy$(15,526,996) Other$(5,065,238) Totals$244,801,735 Simple Cost Avoidance 24

25. Case Example: Louisiana Greater New Orleans Primary Care Access and Stabilization Grant  Thirteen of the 25 organizations achieved recognition by NCQA as PCMHs at 36 clinic locations (ranging from levels 1-3), and more clinics are expected to achieve the recognition in 2009.  All organizations have implemented 24/7 access to clinician by phone and same day appointments for urgent care.  The total system volume (number of individuals served) has increased by 15% every six-month period starting March 2007 for outpatient primary and behavioral health care.  The 25 participating organizations have expanded the number of service delivery sites from 67 pre-grant to 91 today. 25 Source: PCPCC 2009 Pilot Guide

26. Recognition Programs for PCMH Developed or Under Development Quality Organizations PCMH Standards Activity 2010 26

27. 27 Standard 1: Access and Communication A. Has written standards for patient access and patient communication** B. Uses data to show it meets its standards for patient access and communication** Pts 4 5 9 Standard 2: Patient Tracking and Registry Functions A. Uses data system for basic patient information (mostly non-clinical data) B. Has clinical data system with clinical data in searchable data fields C. Uses the clinical data system D. Uses paper or electronic-based charting tools to organize clinical information** E. Uses data to identify important diagnoses and conditions in practice** F. Generates lists of patients and reminds patients and clinicians of services needed (population management) Pts 2 3 6 4 3 21 Standard 3: Care Management A. Adopts and implements evidence-based guidelines for three conditions ** B. Generates reminders about preventive services for clinicians C. Uses non-physician staff to manage patient care D. Conducts care management, including care plans, assessing progress, addressing barriers E. Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities Pts 3 4 3 5 20 Standard 4: Patient Self-Management Support A. Assesses language preference and other communication barriers B. Actively supports patient self-management** Pts 2 4 6 Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety checks C. Has electronic prescription writer with cost checks Pts 3 2 8 Standard 6: Test Tracking A. Tracks tests and identifies abnormal results systematically** B. Uses electronic systems to order and retrieve tests and flag duplicate tests Standard 7: Referral Tracking A. Tracks referrals using paper-based or electronic system** Pts 7 6 13 Pts 4 Standard 8: Performance Reporting and Improvement A. Measures clinical and/or service performance by physician or across the practice** B. Survey of patients’ care experience C. Reports performance across the practice or by physician ** D. Sets goals and takes action to improve performance E. Produces reports using standardized measures F. Transmits reports with standardized measures electronically to external entities Pts 3 2 1 15 Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support Pts 1 2 1 4 **Must Pass Elements NCQA PPC-PCMH Content and Scoring

28. Scoring: Building a Ladder to Excellence Level 1: 25-49 Points; 5/10 Must Pass Level 2: 50-74 Points; 10/10 Must Pass Level 3: 75+ Points; 10/10 Must Pass Increasing Complexity of Services

29. 29Source: NCQA, December 2009

30. PCMH Implementation Tools- Report Release “Aligning Incentives and Systems” Promoting Synergy Between Value-Based Insurance Design and the Patient Centered Medical Home”  Makes the business value case for PCMH showing link to VBID  Case studies: Whirlpool Company, the State of Washington, the City of Battle Creek, Mich., IBM, Roy O. Martin Lumber, CIGNA, Universal American, Geisinger Health System/Health Plan, Aetna and the State of Minnesota.  Authored by the Center for Employer Engagement in partnership with the National Business Coalition on Health and the University Michigan’s Center for Value-Based Insurance Design 30

31. Meaningful Use: Meaningful Connections  Defines health IT capabilities essential to PCMH.  Crosswalks capabilities with functional priorities supporting PCMH.  Explores how patients/consumers are currently using health IT to connect.  Representative sample of 19 case example responses from primary care providers.  Appendices include Guidelines for PCMH Demonstration Projects Consumer Principles Consumer Toolkit 31

32. Patient Centered Primary Care Collaborative “Purchaser Guide” Released July, 2008  Developed by the PCPCC Center for Benefit Redesign and Implementation in partnership with NBCH and the Center’s multi-stakeholder advisory panel.  Guide offers employers and buyers actionable steps as they work with health plans in local markets - over 6000 copies downloaded and/or distributed.  Includes contract language, RFP language and overview of national pilots.  Includes steps employers can take to involve themselves now in local market efforts.  The PCPCC is holding a series of Webinars, sponsored by Pfizer, on the Purchaser Guide. 11 32

33. Patient Centered Primary Care Collaborative “Proof in Practice– A Compilation of Patient Centered Medical Home Pilot and Demonstration Projects” Released October 2009  Developed by the PCPCC Center for Multi-stakeholder Demonstration through a grant from AAFP offering a state-by-state sample of key pilot initiatives.  Offers key contacts, project status, participating practices and market scan of covered lives; physicians.  Inventory of : recognition program used, practice support (technology), project evaluation, and key resources.  Begins to establish framework for program evaluation/ market tracking. 12 33

34. 34 Patient Centered Primary Care Collaborative “A Collaborative Partnership – Resources to Help Consumers Thrive in the Medical Home” Released October 2009 Included in the Guide: 1. PCPCC activities and initiatives supporting consumer engagement; 2. Research and examples surrounding consumer engagement in PCMH demonstrations; 3. Tools for consumers and other stakeholders to assist with PCMH education, engagement and partnerships; and 4. A catalogue of resources that provides descriptions of and the means to obtain potential resources for consumers, providers and purchasers seeking to better engage consumers.

35. Information Flow- Consumer Materials What consumers can expect- PCMH consumer principles (brochure) Guidance to create your own practice brochure in support of PCMH model (paper) Four minute video for waiting room viewing; deep-dive on PCMH (Flash) Promotes Primary Care (brochure) Deep-dive focus on PCMH (brochure) 35

36. On September 16, 2009 HHS Secretary Sebelius, along with Director of White House Office of Health Reform Nancy-Ann DeParle and Vermont Governor Jim Douglas, announced that the Centers for Medicare and Medicaid Services (CMS) will establish a demonstration program that will enable Medicare to join Medicaid and private insurers in innovative state-based advanced primary care initiatives. New Medicare Demonstration Design will include mechanisms to assure it generates savings for the Medicare trust funds and the federal government Private insurers work in cooperation with Medicaid to set uniform standards for “Advanced Primary Care (APC) models” Provide incentives for doctors to spend more time with their patients and offer better coordinated higher- quality medical care States Wishing to Participate in the New Demonstration Must: Certify they have already established similar cooperative agreements between private payer and their Medicaid program; Demonstrate a commitment from a majority of their primary care doctors to join the program; Meet a stringent set of qualifications for doctors who participate; and Integrate public health services to emphasize wellness and prevention strategies. MEDICARE-MEDICAID ADVANCED PRIMARY CARE DEMONSTRATION INITIATIVE 36

37. Encouraging Movement White House, Senate and House Major provisions of the Health Care Reform bills relevant to Primary Care and PCMH  State option to provide health homes for enrollees with chronic conditions. Provide States the option of enrolling Medicaid beneficiaries with chronic conditions into a health home.  Pediatric Accountable Care Organization demonstration project. Establishes a demonstration project that allows qualified pediatric providers to be recognized and receive payments as Accountable Care Organizations (ACO) under Medicaid.  Establishment of Center for Medicare and Medicaid Innovation within CMS. The purpose of the Center will be to research, develop, test, and expand innovative payment and delivery arrangements to improve the quality and reduce the cost of care provided to patients in each program.  Training in family medicine, general internal medicine, general pediatrics, and physician assistantship. Provides grants to develop and operate training programs, provide financial assistance to trainees and faculty, enhance faculty development in primary care and physician assistant programs, and to establish, maintain, and improve academic units in primary care.  Expanding access to primary care services and general surgery services. Beginning in 2011, provides primary care practitioners, as well as general surgeons practicing in health professional shortage areas, with a 10 percent Medicare payment bonus for five years.  Payments to primary care physicians. Requires that Medicaid payment rates to primary care physicians for furnishing primary care services be no less than 100% of Medicare payment rates in 2013 and 2014. Other Items:  ‘Grants to Establish Community Health Teams to Support a Medical Home Model’: the Secretary of HHS would establish a grant program to creating the “community health team which is community-based, multi disciplinary, interprofessional teams (on the model of medical home) to increase access to comprehensive coordinated care.  Enhancing Health Care Workforce Education and Training -. Priority is given to programs that educate students in team-based approaches to care, including the patient-centered medical home. Authorization is set at $125 million. 37

38. CMS Activity and the PCMH Planned Demonstrations Medicare Medical Home Demo Status - on hold pending recent health care reform legislation Multi-Payer Advanced Primary Care Practice Demo Status - invitation to states and solicitation in clearance Federally Qualified Health Centers Advanced Primary Care Practice Demo Status - under development 38

39. Test Drive the New PCPCC Website !  Soft Launch 3.18.2010  Membership Webinar 4.08.2010 -Recorded  Major features include Master calendar listing all PCPCC events On-line and interactive Pilot Guide User portals (consumer & patients, employer & health plans, providers & clinicians, federal & state government Center portals and updates http://www.pcpcc.net 39

40. UPCOMING COLLABORATIVE EVENTS Thursday, July 22, 2010 - Washington D.C., Stakeholder Meeting - Ronald Reagan Building and International Trade Center Thursday, October 21, 2010 - Washington D.C., Annual Summit - Ronald Reagan Building and International Trade Center 40

41. CONTACT INFORMATION Visit our website – http://www.pcpcc.net To request any additional information on the PCMH or the Patient Centered Primary Care Collaborative please contact: Edwina Rogers Patient Centered Primary Care Collaborative Executive Director 202.724.3331 202.674.7800 (cell) erogers@pcpcc.net The Homer Building 601 Thirteenth St., NW, Suite 400 North Washington, DC 20005 41