Patient-Centered Medical Home: The Process & Initiative

Adele AllisonNational Director of Government Affairs, SuccessEHS

Notable Acronyms

• PCMH – Patient Centered Medical

Home

• PPACA – Patient Protection and

Affordable Care Act

• NCQA – National Committee for

Quality Assurance

• HRSA – Health Resources and Services

Administration

• AHRQ – Agency for Healthcare

Research and Quality

• ACO – Accountable Care

Organization

PCMH Initiatives

• 27 multi-stakeholder projects in 20 states

• 21 states with single, commercial payer project

• 38 states with Medicaid/CHIP projects

• Only 5 states do not have PCMH

AHRQ*

*Agency for HealthcareResearch and Quality

• Primary Care with orientation toward whole person and relationship-based collaboration• Caregiver (“Home”) is

accountable for majority of physical and mental health through a team

• Home coordinates care needs across the health continuum• Patient accessibility is increased• Systems-based approach to

Quality and Safety (CDS)

Health Plans & NCQAAdd Recognition Seals to Provider Directories

Aetna Blue Cross Blue Shield AssociationBlue Cross Blue Shield of Western New York Blue Shield of Northeastern New YorkCIGNA CDPHPGeoAccess Highmark Blue Cross Blue ShieldHumana Medical Mutual of OhioMVP Health Plan, Inc. United

Assistance with Recognition by Supporting Data CollectionBlue Care Network of Michigan Highmark Blue Cross Blue ShieldMVP Health Plan of New York Oxford of New YorkUnited (4 areas)

Pay Rewards for Achieving Recognition or Supplement Fees for Recognized ProvidersAnthem (Virginia) Bridges to ExcellenceBlue Cross Blue Shield of South Carolina/Companion

CareFirst (DC-Maryland and Georgia)

CDPHP ConnectiCareHealthAmerica (Pennsylvania) Health First (Florida)Highmark Blue Cross Blue Shield Independence Blue CrossMVP Health Plan of New York Oxford of New YorkPriority Health Silicon Valley HIT

Use Recognition as a Requirement for Entry into High-Performance NetworksAetna CIGNAUnited

PPACA – Accountable Care Organizations

• ACOs contract to provide services for a defined population of Medicare patients • ACOs share savings if quality

objectives are achieved and performance measures met• Model is effective January 1,

2012

• ACO models include: – Integrated Delivery Systems (e.g. Kaiser,

Group Health Coop.)–Multi-specialty Group Practices (e.g. Mayo

Clinic)–Physician-Hospital Organizations (PHOs)– Independent Physician Associations (IPAs)–Virtual Physician Organizations

• Must be Physician-led with PCMH at the hub

PCMH Movement& The Hill

• HHS - Workforce Development and Training - $250M o↑ PCP Residency Slotso Support PA training in Primary Careo Support full-time nursing careerso Establish new NP-led Clinicso Encourage state planning for health

care professional workforce needs

• Medicaid / Medicare PilotsoPPACA§ 2703 – New Medicaid state

plan option to cover PCMH for certain chronic condition enrollees – 90% federally funded care for first 8 Quarters

oCMMI – Research, develop, test and expand innovative payment / delivery models

Legislation & PolicyPPACA or

Reconciliation Act Section

Opportunity Description Effective Date

PPACA § 5501 Increased Reimbursement

PCPs receive 10% increase in reimbursement for Medicaid and Medicare primary care services.

FY 2011-2016

Reconciliation § 1202 Increased Reimbursement

Medicaid payment rates to PCPs for primary care services shall be no less than 100% of the Medicare payment rates.

2013 and 2014

Reconciliation § 1202 Increased Reimbursement

100% of federal funding for incremental state costs to meet the above-noted Medicaid requirement.

2013 and 2014

PPACA § 4104-6 Prevention Support

Improved access for preventive services, including Medicaid and Medicare clinical preventive services recommended with a grade A / B by the USPSTF and adult immunizations recommended by ACIP.

CY 2011

PPACA § 4108Prevention

Support Incentives for prevention of chronic disease for Medicaid patients

As early as CY2011

PPACA § 2001 Coverage / Service

Expansion

$11B in new funding over 5 years for health center program expansion ($9.5B for operational capacity and $1.5B for facility improvement, expansion, and construction).

FY 2011

PPACA § 5207 Workforce Development

Expands education/training under Titles VII and VIII of the Public Health Service Act with:$1.5B in new funding for the National Health Service Corps for 15,000 PCPs in HPSAs.National Health Service Corps members may count up to 50% of their time spent teaching towards service obligation.

FY 2010 - 2016

Legislation & PolicyPPACA or

Reconciliation Act Section

Opportunity Description Effective Date

PPACA § 5508 Workforce Development

Authorizes health centers to develop residency programs and pays for CHCs operating teaching programs.

FY 2010 - 2012

PPACA § 2706Payment Delivery

PPACA establishes Accountable Care Organization (ACO) contracting with CMS effective January 1, 2012. Included is a 5-year Medicaid pediatric demonstration with shared savings incentives.

CY 2012

PPACA § 3022 Payment Delivery

Establishment of ACOs for Medicare shared savings incentives with CMS. CY 2012

PPACA § 2703 Health HomeMedicaid State Plan Option with enhanced FMAP for enrollees with 2 chronic conditions (or 1 condition with a risk for a second) can designate qualified provider as their health home for care management, coordination, health promotion, transitional care, and community / social support services.

Beginning CY 2011

PPACA § 3502 Health HomeGrants to create community health teams to support PCMH development for patients with chronic conditions.

CY 2013

PPACA § 3503 Care DeliveryGrants available to pharmacists for medication therapy management (MTM) May 1, 2010

Legislation & PolicyPPACA or

Reconciliation Act Section

Opportunity Description Effective Date

PPACA § 10333 Care DeliveryGrants available for creation of Community Based Collaborative Care Networks (hospital + FQHC) for comprehensive care coordination for low-income populations. Grants may be used for:Enrollment assistance and provider assignmentCase management and care managementHealth outreach through neighborhood health workersTransportationExpansion for tele-health, after hours services or urgent careDirect patient care services

FY 2011 - 2015

PPACA § 1139B ReportingAdult quality health measures for Medicaid-eligible adults through a Medicaid Quality Measurement Program.

CY 2013

PPACA § 3015, 10305 Reporting

Grants for data collection and other public reporting requirements FY 2010 - 2014

NCQA – Role & Process

• Program contains 6 standards consisting of 27 elements and 149 factors.• Standards contain “Must Pass” and

non-must pass elements• Elements are associated with points,

resulting recognition Level• 3 Levels – Level 1 (lowest) to Level 3

(highest)

NCQA-PPC-PCMH 2011

Level 3 85-100 points + all 6 must pass elements

Level 2 50-84 points + all 6 must pass elements

Level 1 35-59 points + all 6 must pass elements

No Recognition 34 points or less and/or less than 6 must pass elements

NCQA PCMH 2011 ScoringPoints

NCQA PCMH 2011Standard and Element

Number of Factors

Must Pass?

20 PCMH Standard 1: Enhance Access and Continuity 344 Element A: Access during office hours 4 Yes4 Element B: Access after hours 5 No2 Element C: Electronic Access 6 No2 Element D: Continuity 3 No2 Element E: Medical Home Responsibilities 4 No2 Element F: Culturally & Linguistically Appropriate Services (CLAS) 4 No4 Element G: Practice Organization 8 No

17 PCMH Standard 2: Identify and Manage Patient Populations 353 Element A: Patient Information 12 No4 Element B: Clinical Data 9 No4 Element C: Comprehensive Health Assessment 10 No5 Element D: Using Data for Population Management 4 Yes

17 PCMH Standard 3: Plan and Manage Care 234 Element A: Implement evidence-based guidelines 3 No3 Element B: Identify High-Risk Patients 2 No4 Element C: Manage Care 7 Yes3 Element D: Management Medications 5 No3 Element E: Electronic Prescribing 6 No9 PCMH Standard 4: Provide Self-Care and Community Support 106 Element A: Self-Care Process 6 Yes3 Element B: Referrals to Community Resources 4 No

18 PCMH Standard 5: Track and Coordinate Care 256 Element A: Test Tracking and Follow-up 10 No6 Element B: Referral Tracking and Follow-up 7 Yes6 Element C: Coordinate with Facilities / Care Transitions 8 No

20 PCMH Standard 6: Measure and Improve Performance 224 Element A: Measures of performance 4 No4 Element B: Patient / Family feedback 4 No4 Element C: Implements Continuous Quality Improvement 4 Yes3 Element D: Demonstrates Continuous Quality Improvement 4 No3 Element E: Performance Reporting 3 No2 Element F: Report Data Externally 3 No

100 149 6

10 Commandments of PCMH Health IT Support

1. Collect standardized, accurate, essential data → Knowledge Base, eRx, Interfaces

2. Incorporate data from outside systems → Interfaces / HIE

3. Support care coordination → Referral Tracking / HIE

4. Facilitate medication reconciliation → eRx, Rx History

5. Capture/Respond to population health needs → Clinical Event Mgmt. Tools

6. Link to community resources → Evidence-based CDS

7. Collect, store, measure and report on individual and population process, outcomes and quality → Registry, Ad Hoc Reporting, Pop. Mgmt., Dashboards

8. Engage care team in decision support at the point of care → CDS, Pop. Mgmt.

9. Facilitate provider engagement to reduce risk stratification → Referral Management, HIE, CPOE with audit trails and alerts

10. Support patient self-management and enhance patient access/communication → Patient Portal, Surveys, Summaries, Education

HRSA & PCMH

• HRSA Patient-Centered Medical Health Home Initiative (PCMHH Initiative)• Provides cost coverage for

recognition process fees ($580-$4,080+ depending on number of clinicians)

• Coordinating strategy with primary care associations, national cooperative agreements and Health Center Controlled Networks (HCCNs)

• Eligibility based upon Section 330 funding• HRSA provides 3 types of:− Technical assistance− Training− Mock Surveys− Consultant advice

• Health Centers must complete a Notice of Intent to receive HRSA support

• NOI available at www.bphc.hrsa.gov/policy/pal1101

• Completed NOI should be emailed to PCMHHinitiative@hrsa.gov

• Once approved, NCAQ will provide PCMH standards and guidelines, instructions and details regarding application

• Additional Links:− Helpline: 877.974.2742 or bphchelpline@hrsa.gov− NCQA Project Liaison: 888.375.7585 or PCMH-

GRIP@ncqa.org

• Does your Vendor offer PCMH Specialized Project Management?− Gap Analysis− Workflow redesign− Coordination with development of Policies &

Procedures− Reporting Assistance

Call to Action: Why do PCMH?

• National Recognition• Increased Market Competitiveness• Potential Increased Reimbursement• Aligns with PPACA Legislation• Added Structure for CHC Expansion• Parallels and Compliments Meaningful Use• Aligns with new and existing pilots /

demonstration projects• Positions for ACOs under PPACA

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