patient-centered medical home an educational and practice challenge new mexico medical society july...

Patient-Centered Medical HomeAn Educational and Practice Challenge

New Mexico Medical SocietyJuly 17, 2009

2Physician Practice Connections--Patient-Centered Medical Home

Overview of Presentation

• Driving forces behind Patient Centered Medical Home

• Origins of Medical Home• Need for qualification and evaluation of

PCMH• Development of PPC-PCMH • Beyond measurement: the challenge to

Education and Practice– What is needed for the medical home to

succeed?– The challenge to educational groups at all

levels


Why do we need a “new” system (some would say we don’t have one now)

• Costs have (for 50 years), and continue to, rise faster than GDP – Uninsured, underinsured and related issues– Can’t improve access without controlling

costs– Major variation in costs WITHOUT

relationship to quality (national/international)

• Major gaps in quality– Hospital deaths and readmissions– In ambulatory care-about 50/50 chance of

getting needed services


Primary Care Has Changed….Negatively

• Increasing need for PCPs– Population age 85 and over will increase 50% from

2000 to 2010– Aging population means an increase in care for

complex and chronic medical conditions• Decreasing number of PCPs

– Projected shortage of 200,000 PCPs by 2020– Plunging interest in primary care

• Entering internal medicine residents down to 10 % in 2008 from 54% in 1998.

• Family Medicine: not filling residencies and high proportion filled by non US medical graduates

– Primary care physicians are overworked and dissatisfied

– Compensation is bottom of pay scale for physicians


Median Compensation for Selected Medical Specialties

Data are from the Medical Group Management Association Physician Compensation and Production Survey, 1998 and 2005


Yet Primary Care Leads to Better Quality and Lower Costs

• Higher ratio of PCPs to specialists is associated with improved health outcomes and lower costs (Starfield-both international and within US data) – Adding 1 family practitioner per 10,000

people associated with 70 fewer deaths per 100,000 (9% reduction in mortality) and lower costs (fewer ambulatory sensitive admissions)

– Specialists practicing outside their specialty area leads to an increase in mortality and cost (Fisher)


Impact of Primary Care Decline• Patients are dissatisfied and so are

doctors– Patients can’t get timely access to acute care

• Inability of patients to get timely appointment was 23% in 1997 and rose to 33% in 2005

– Physicians hampered in provision of comprehensive chronic care• Lack time and state-of-the-art systems and

processes (the hamster on a treadmill effect) • Pay for procedures- no compensation for nearly

25% of work that occurs between visits, for quality or efficiency

• Gaming rather than value (procedure hobbies that reimburse well versus counseling)


Key Steps to a true “Health Care System”

• Primary Care Patient Centered Medical

Home as key building block• Implementation and use of health

information technology and care systems at all levels of health care

• Integration of care (real or virtual)• Reimbursement linked to desired

process and outcomes of care (pay for what you want)

• Measurement and feedback to determine if you are getting where you want to be


The Current Model of Care:Connection by Billing


Future Model of Care: Step II Patient Centered “Medical

Neighborhood”

Patient-CenteredMedical Home

Sub-specialty “Medical Home Neighbor”

Sub-Specialty Procedural Practice

Insurer

Hospital

Data Center


Patient Centered Medical Home

A blending of concepts and critical building block for health system

change


The Medical Home “Defined”ACP, AAFP, AAP, AOA

• Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

• Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

• Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

• Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.


The Patient Centered Medical Home is a journey not a destination

“In transforming one's practice there is no "there there". There is no moment when the work is completely done.

Those who think that the ultimate goal is achieving NCQA recognition will be disappointed. The goal is continuous transformation. Those practices who have a strong internal culture, a capacity to change, a sense of excitement and a perpetual ability to critically examine their own practices are best suited for this new environment.”


Primary Care

• Multiple formulations from 1960’s on• Core concepts of

– First contact – Coordinated– Comprehensive– Continuous

• Strong empiric base linking primary care to higher quality and lower cost (within US and international)


Wagner Model for Effective Prevention and Chronic Illness

Care


Wagner Model Chronic (Planned) Care Model

• Formulated in 1980’s but with prior roots in primary care and elsewhere

• Based on varying amounts of empiric evidence (qualitative to RCT’s)

• Since developed, multiple studies evaluating model and components of the model (www.improvingchronicillness.org)

• Successful application to both chronic and preventive care (thus “planned care”)

• Empiric basis bolstered by Shortell work on systems and quality


Patient Centeredness

• Studies and formulations funded and led by Picker

• Defined in “Crossing the Quality Chasm by IOM “the system of care should revolve around the patient, respect patient preferences and put the patient in control”

• Recent work funded by Commonwealth –including work by NCQA and others in refining the definition and creating measures (ACES, CG-CAHPS, supplement to CG CAHPS)


DecisionSupport

Self-MtgSupport

Comprehensive

First Contact

Perfect Confluence?

What’s Included?(Infrastructure)

How Much Used?(Extent)

What Functions?(Implementation)

Evidence

Wagner CCM Community Linkages

InformationSystems

Delivery system design

Coordinated

Continuous

Medical Home

Primary Care


Theoretical Frameworks Informing Development of PPC_PCMH

Based on best available empiric evidence in each area and on testing of reliability and validity of elements in field tests using on site audit as “gold”

standard

Chronic Care Model

Patient Centered Care

Cultural Competence

Medical Home

Clinical information Systems

Decision SupportPatient Self-

ManagementDelivery System

RedesignCommunity LinkagesHealth Systems

Respect Patient ValuesAccessible Family-Centered Continuous Coordinated Community LinkagesCompassionate Culturally Appropriate Emotional Support Information and

Education Physical ComfortQuality Improvement

Culturally competent interactions

Language services

Reducing disparities

Personal physicianPhysician directed

teamWhole person

orientationCare is coordinated

and integratedQuality and safetyEnhanced access

PRIMARY CAREFirst contact-comprehensive-continuous-coordinated


A Critical Missing Ingredient: REIMBURSEMENT THAT SUPPORTS

GOOD CARE


Fee For Service Reimbursement: The Road to Ruin for Primary Care

• Rewards and encourages volume and new procedures-not primary care

• Is largely influenced and controlled by CPT-4 coding panels and the Resource Utilization Committee (ie: sub-specialists)

• Makes first contact, continuous, coordinated and comprehensive care an economic hardship for most practices

• Treadmill-have to see 20 patients a day to pay for staff-and 10 more for clinicians to make a reasonable living


Conclusion: Too Little

Wrong Incentives


Linkage of PCMH to Reimbursement:

Balanced (and increased) Payment

Fee Schedule for Visits/Procedures

Payment per Patient for Qualified Medical Homes(services not normally reimbursed)

Pay for PerformanceQuality, Resource Use and Patient Experience


Goals for PCMH Implementation

• Improved quality for preventive services and care of persons with chronic illness

• Moderation-or at least, more rational use of resources (lower ambulatory sensitive hospitalization, reordered labs etc)

• Improved patient centeredness as expressed in patient experience of care surveys

• Enhanced reimbursement for primary care • Improved clinician and staff satisfaction

with primary care practice


How do we “know” a PCMH when we see one?


Need for a Standardized Tool for QUALIFICATION as PCMH

• If payers are going to provide extra reimbursement to PCMHs, they need an valid and reliable, actionable tool

• When reimbursement at stake, major problems with – Use of practice (clinician) surveys without

documentation or on site verification– Use of clinical performance measures or

patient experience of care (sample size, cost, risk adjustment)

• Critical for practices to have standardization since practices may participate in projects for multiple payers


PPC-PCMH Development

• Existing PPC 2006 (based on PCM) modified with input from AAFP, AAP, ACP and AOA – Align standards with Joint Principles

of PCMH created by four groups– Incorporate critical attributes of

PCMH not in CCM – Define foundational elements (“must

pass” requirements)Endorsed by NQF


Research Findings: Validity of Self-Report

• Practices can report on systems, however…

– Overall agreement with an on-site audit ranges from high (clinical information systems, quality improvement) to low (care management, population management)

• Several factors may explain lack of agreement– Variable implementation of systems across sites and

conditions– Variations in staff members’ exposure to systems– Lack of familiarity with systems

Conclusion: Need Audit or Documentation


Correlation of Systems, Clinical Performance

• Published and in process research on PPC– Presence or absence of EMR per se, correlates ONLY

WEAKLY with clinical measures• However, practices with fully functional EMR’s achieve highest

scores on PPC

– Overall PPC score, and some sub-scores have positive correlation with higher clinical performance on measures tested (diabetes, CV, depression)

– Overall PPC score and some sub-scores have positive coorelation with lower inpatient days for ambulatory sensitive conditions

– Overall PPC score does NOT appear to correlate with overall patient experiences of care but with selected sub-components (ACES- questions with variance attributable to practice level)

More research needed on all aspects –especially on relationship to cost and utilization: ER visits; tests;

specialty care; drug interactions etc


PPC-PCMH Content and ScoringStandard 1: Access and CommunicationA. Has written standards for patient access and

patient communication**B. Uses data to show it meets its standards for

patient access and communication**

Pts

45

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

33

64

3

21

Standard 3: Care ManagementA. 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

35

5

20

Standard 4: Patient Self-Management Support A. Assesses language preference and other

communication barriersB. Actively supports patient self-management**

Pts

24

6

Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety

checksC. Has electronic prescription writer with cost

checks

Pts33

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

Pts7

6

13

Standard 7: Referral Tracking A. Tracks referrals using paper-based or

electronic system**

PT4

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

33

3

21

15

Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support

Pts121

4

**Must Pass Elements


PCMH Must Pass Elements1. PPC1A: Written standards for patient access and patient

communication

2. PPC1B: Use of data to show meeting standards

3. PPC2D: Use of paper or electronic-based charting tools to organize clinical information

4. PPC2E: Use of data to identify important diagnoses and conditions in practice

5. PPC3A: Adoption and implementation of evidence-based guidelines for three conditions

6. PPC4B: Active support of patient self-management

7. PPC6A: Tracking system to test and identify abnormal results

8. PPC7A: Tracking referrals with paper-based or electronic system

9. PPC8A: Measurement of clinical and/or service performance

10. PPC8C: Performance reporting by physician or across the practice


How PPC-PCMH Recognition Works

Physician/practice• Self-assess, collect data using Web-based software

• Submit documentation to NCQA when ready

• May be asked to submit more data if needed

NCQA • Evaluates and scores all applications

• Checks licensure of physician

• Audits a sample of applications

• Posts Recognized physicians on web

• Distributes list of Recognized physicians monthly to health plans and others

• Physicians sent media kit, press releases, letter & certificate


Myths• Small practices can’t qualify (>20% of

qualified practices are solo physician sites/practices)

• Passing (25 points) is too hard (practices do not have to submit tool until they score above passing)

• Passing (25 points) is too easy (estimate fewer than 15% of practices could pass without making changes)

• You have to have an EMR to pass (can get nearly 50 points without)


Office SystemsDecision Support

Information Technology Delivery System Design

Patient Support

Implementing and Evaluating PCMHImplementing and Evaluating PCMH

Inputs

Evaluation

Programs

Tools

PatientExperience

of CareMeasures

(CG-CAHPS)

Clinical Process And

Outcome Measures(Recognition programs

& Group/plan data)

Office Systems

Assessment (PPC-PCMH)

Patient CenteredOngoing Care

IndividualClinician-Staff

Attitudes, behaviorsand proficiencies

Educational Support

Output

MOC(Boards)

Practice Evaluation Programs NCQAQualification


What Will be Needed for PCMH to Succeed?


Education, Education, Education

• Education is NOT lectures or traditional CME

• Education must be at all levels –student, resident, and practice-and all types of practitioners and support staff


Education- Practitioners

• Knowledge, Skills, Attitudes-as individuals– Collaborative “team” practice (clinical

staff, support staff and other physicians)

– Population health-as a link between personal and public health

– Quality measurement and improvement basics

– Patient self (or better “collaborative) health and care management support


Some Promising Models (of many)• New York City

– Department of Health providing EHR to 2,000 MDs serving Medicaid population; implementation and QI support

– Goal to reach PPC-PCMH Level II within 2 years• Mid-Hudson Valley

– 150 practices participating in THINC consortium with common EHR, interoperability and implementation support

– Goal to reach PPC-PCMH Level II within 2 years• North Carolina Medicaid

– Nurse care managers shared by practices-reported >50 million in savings/year

• Geisinger (reported in Health Affairs)– Introduced in Geisinger Health System– Reduced ambulatory care sensitive hospital admissions

• CMS Demonstration– Large Scale (>200 practices in each of eight regions)– Practices could potentially earn nearly $100,000/MD/year– Will use nurse case manager model similar to North Carolina


Is the PCMH enough?


Future Model of Care:Patient Centered Medical Home as

Foundational

Sub-specialty “Medical Home Neighbor”

Sub-Specialty Procedural Practice

Insurer

Hospital

Patient-CenteredMedical Home


The Future Model of Care: Step IIIPatient Centered Integrated Delivery

System

Sub-specialty “Medical Home Neighbors” Referrals and Procedures

Insurer

Patient Centered Hospital

Patient Centered Medical Home

Data Center


Summary: Issues to Consider

• PCMH is not THE answer to our cost and quality problems, but a vital building block

• Challenge to provide sufficient help to practices to become PCMH’s to enable them to achieve and demonstrate the cost savings and quality improvement we need

• Challenge to build on the PCMH to create virtual accountable entities (for primary, specialty care and hospital care)

patient-centered medical home an educational and practice challenge new mexico medical society july...

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