Overview of The Patient Centered Medical Home (PCMH) Movement

HRSA Office of Rural Health Grantee Partnership Meeting

September 2, 2009Shari Erickson

Senior Associate, Center for Practice Improvement & Innovation

Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and protection.President Harry Truman

Text from a speech he delivered to a joint session of Congress in 1945

So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year.

President Barack ObamaText from a speech he delivered to a joint session of Congress , February 24, 2009

The Case for Health Care Reform; Case for PCMH

Poor access to care, especially for the uninsured Rising costs and gaps/variation in quality of

services Increase in chronic conditions Need for better care coordination Dysfunctional payment system; rewards volume,

face-to-face services Impending “collapse” of primary care Purchasers’ demand for accountability and

transparency United States is lagging internationally

Presentation Outline Overview of the patient-centered medical home

model Joint Principles PCMH recognition program Features of a PCMH practice Growing support for the PCMH model Efforts to test the PCMH model Additional Activities Underway and in the Future

High-Level Medical Home Overview ACP and others refer to medical home as the Patient Centered Medical Home

Strengthening the physician-patient relationship Getting patients the care they want and need

when they need it Vision of primary care as it should be Framework for organizing systems of care at

both the micro (practice) and macro (society) level

Model to test, improve, and validate Important component of more comprehensive

reform

Evolution of the PCMH “Joint Principles” ACP, American Academy of Family Physicians

(AAFP), American Academy of Pediatrics (AAP), and American Osteopathic Association (AOA) have similar positions in promoting PCMH

ACP, AAFP, AAP, and AOA—representing 330,000 physicians—establish PCMH “joint principles” in March 2007 to provide standard definition of delivery model and describe the environment necessary to support it

These joint principles guide the collective actions of the organizations to further develop, promote, and test the PCMH

Joint Principles 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

Team-based care: NP/PARN/LPNMedical AssistantOffice StaffCare CoordinatorNutritionist/EducatorPharmacistBehavioral HealthCase ManagerSocial WorkerCommunity resourcesDM companiesOthers…

Joint Principles-Recommended Supporting Payment Structure

Payment model is intended to facilitate and sustain improved care delivery and provide a mix of incentives to optimize patient care

Bundled, severity-adjusted care coordination fee paid on a monthly basis for the following components• The physician and non-physician clinical staff work

required to manage care outside a face-to-face visit

• The health information technology and system redesign incurred by the practice

Continued per-visit, fee-for-service (RBRVS) payment Performance-based bonus payments based on

evidence-based measures of care

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

National Committee on Quality Assurance (NCQA) announced a voluntary recognition process based on its Physicians’ Practice Connection (PPC) module, the PPC-PCMH in January 2008• ACP, AAFP, AOA, and AAP helped NCQA develop the module

Other entities can develop PCMH recognition process Recognized PCMHs would also be accountable for quality

of care by reporting on evidence-based clinical and patient experience measures—provides retrospective assurance

NCQA PPC-PCMH Recognition Module; Major Domains/Standards 1. Access &

Communication2. Patient Tracking &

Registry Functions3. Care Management4. Patient Self-

Management Support5. Electronic

Prescribing

6.Test Tracking7.Referral Tracking8.Performance

Reporting & Improvement

9.Advanced Electronic Communication

Each standard contains sub-elements

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

Key Points for Level 1 PCMH Does not require electronic health record Will require registry & tracking functions Emphasis is on providing better care through:

• Access to care

• Organization of office structure & processes

• Enhancing patient self-management; addressing health literacy issues

• Introduction of evidence-based guidelines, measurement & quality improvement

Level 2 → Level 3

Advanced access options for patients Electronic health record More, and more complex care coordination

and patient support Robust population management Advanced reporting and quality

improvement initiatives Additional technology solutions

More Features of a PCMH Practice Uses each team member to his/her highest

capability Supports cultural competency training for

clinical team Understands health literacy Establishes connections to the community and

available resources Provides extensive self-management support Engages a Patient/Family Advisory Group

More Features of a PCMH Practice Provides individualized written care plans

and monitors adherence to plan with patient/family

Assesses barriers to adherence and initiates plans to overcome them

Collaborates with other physicians & institutions to insure timely access to health information

Manages transitions of care seamlessly

NCQA Recognition Activity* 149 practices have received recognition

across 17 states• 46% Level 1• 4% Level 2• 50% Level 3 (12 of 75 in practices of 1-2 physicians)

Practices more likely to seek recognition when/where tied to reward

Smaller practices (in number of physicians) somewhat more likely to be Level 1; larger practices somewhat more likely to be Level 3

* Source: NCQA, as of June 12, 2009

Growing Support for the PCMH Model

Many supporting organizations have come together through the Patient Centered Primary Care Collaborative (PCPCC), which formed in 2007 and has over 560 member organizations, including:• Organizations representing over 350,000 physicians—including ACP and

other primary care societies, American College of Cardiology, American Academy of Neurology

• Organizations representing over 50 million employees, including large employer umbrella groups, and individual companies such as IBM, General Motors

• All major health plans• CVS Caremark, including MinuteClinic• Consumer organizations including AARP• Bridges to Excellence• State governments and public health departments

PCPCC organizations attest to their support of the PCMH Joint Principles, including the belief that the PCMH will “improve health of patients and the viability of the health delivery system,” and support a better payment model to facilitate implementation

PCPCC on the web: http://www.pcpcc.net

Overview of PCPCC Activities Four Collaborative Centers:

Multi-Stakeholder Demonstrations; Public Payer Implementation; Health Benefit Redesign and Implementation; and eHealth Information Adoption and Exchange

Events: Two stakeholder meetings per year One national summit Weekly calls Collaborative center calls

Products (all available free of charge): Purchasers Guide to the PCMH IT Resource Guide Consumer Materials PCMH Pilot Compilation

Overview of PCPCC Activities (cont.) The Purchasers Guide (http://www.pcpcc.net/content/purchaser-

guide): Aims to address – What is the PCMH? Why should employers/purchasers support it? What strategies and action steps should employers/purchasers consider now?

Meaningful Connections : IT Resource Guide (http://www.pcpcc.net/content/meaningful-connections-it-resource-guide): Identifies the capabilities and functionalities of eHealth applications that experts consider crucial to support PCMH.

Engaging the Consumer (http://www.pcpcc.net/content/engaging-consumer-family-patient-employee-community-etc): Multiple resources from various sources aimed at helping the consumer/patient/family better understand and become engaged in the PCMH model, including a video, brochures, checklists, guides, and white papers.*

PCMH Pilot Compilation (http://www.pcpcc.net/content/pcpcc-pilot-projects): A list of PCMH pilots underway and under development, along with their key features and contact information.

* Can also link to these consumer resources via the ACP website at http://www.acponline.org/running_practice/pcmh/resources_tools/web.htm.

Efforts to Test PCMH Impetus for testing is need for reform/redesign

ambulatory care practice, evidence of the value of primary care, initial evidence from PCMH tests, and support for PCMH concept

Much of initial evidence pertains to large practice settings, integrated delivery groups, e.g. Geisinger (Danville, PA) experience shows 20% reduction in hospital admissions, 7% decrease in overall costs (Health Affairs, Sept/Oct 2008)

Particular need to test in small practices AND in rural areas

Efforts to Test PCMH (cont.) Term “medical home” is used widely and can

mean many things Guidelines for PCMH Demonstration Projects*

- developed by ACP/AAFP/AAP/AOA to provide direction to projects in the planning phase in order to facilitate consistency with the Joint Principles – they include recommendations about: Who should collaborate on the projects; How they should choose practices to participate; What kind of support should be provided to

participating practices; How participating practices should be reimbursed;

and What each project should to do to analyze and

distribute their results. * Detailed guidelines available at: http://www.acponline.org/running_practice/pcmh/demonstrations/guidedemo.pdf

Types of PCMH Test Projects

Multi-payer/multi-player commercial plans

Medicare Advantage Medicaid transformation Safety-Net Medical Home Iniative Medicare FFS

Overview of PCMH Commercial

Pilot Activity• 22 projects• 16 states

• 12 are Multi-stakeholder• 10 are Insurer-based

Source: PCPCC Pilot Report, as of Oct. 2008

Overview of PCMH Commercial

Pilot Activity (cont.)Since October 2008: New commercial PCMH projects

under development in at least 4 more states:• Maryland

• Indiana

• Alabama

• California

Examples of Multi-Stakeholder Efforts to Test PCMH – Pennsylvania Pennsylvania Chronic Care Commission Rollouts

• An integration of the Chronic Care Model and the Patient-Centered Medical Home concept

• Six rollouts across the state – southeast, south central, southwest, northeast, northwest, north central; project underway and to run for three years

• Involves multiple health plans in each area, including Medicaid and Medicare Advantage business

• Includes over 100 internal medicine, family medicine, pediatric, and NP-led practices (in urban, suburban, and rural areas)

• Utilizing NCQA recognition program• 3-component payment structure: (1) prospective infrastructure

development payments, (2) enhanced FFS/capitation via lump sum payments associated with level of achievement on NCQA PPC-PCMH, (3) P4P using a consistent set of core measures by 2010

• Practice support provided by Improving Performance In Practice, a Robert Wood Johnson Foundation funded quality improvement program that is located in several states

Examples of Multi-Stakeholder Efforts to Test PCMH – Louisiana

Source: Karen DeSalvo, presentation to the PCPCC on June 16, 2009 (given by Clayton Williams).

= Identified to have a medical home initiative

Source: National Academy for State Health Policy State Scan, November 2008

Initiatives to Advance Medical Homes in Medicaid/ SCHIP

State Medicaid/SCHIP Innovation (cont.) Over 30 states trying to improve medical home

availability in Medicaid/SCHIP programs - via legislative authority or mandates, Medicaid Transformation Grants, dedicated state resources*

Private Sector Multi-Stakeholder PCMH Pilots Involving Medicaid:• Colorado• Louisiana• Maine• New Hampshire• Rhode Island• Vermont

* Source: National Academy of State Health Policy (NASHP): http://www.nashp.org/files/medicalhomesfinal.pdf discusses 10 states in depth

State Policy PCMH Implementation

Introduced Legislation in 2009

1.California2.New Jersey3.Hawaii4.Maryland5.Nebraska6.West Virginia7.Texas8.Washington 9.Wyoming

Introduced Legislation in 2008

1.Iowa2.Kansas3.Massachusetts4.New Hampshire5.New York6.Oklahoma7.Minnesota8.Washington9.Maryland10.Maine11.Vermont12.Utah

Enacted Legislation in 2007 and 2008

1.Colorado2.Louisiana3.Minnesota4.Iowa5.Washington6.Oklahoma7.Maine8.New York

Safety-Net Medical Home Initiative

For more information: http://www.qhmedicalhome.org/safety-net/index.cfm

Launched by The Commonwealth Fund, Qualis Health and the MacColl Institute for Healthcare Innovation

Project duration: April 2009 – April 2013 Project goal – to develop a replicable and

sustainable implementation model for medical home transformation

Five Regional Coordinating Centers (RCCs) have been selected:• Colorado Community Health Network• Executive Office of Health and Human Services &

Massachusetts League of Community Health Centers• Idaho Primary Care Association• Oregon Primary Care Association & CareOregon• Pittsburgh Regional Health Initiative

Safety-Net Medical Home Initiative (cont.) Each RCC has partnered with 12-15 safety net

clinics in their state. • These collaboratives will receive technical

assistance on practice re-design topics such as enhanced access, care coordination and patient experience.

• They will also receive funding to support a Medical Home Facilitator (who will lead clinic-based quality improvement projects) and other activities.

For more information: http://www.qhmedicalhome.org/safety-net/index.cfm

Medicare Medical Home Demo Authorized under Section 204 of

the Tax Relief and Health Care Act of 2006

3-year demonstration RUC made recommendations for

care management fees

Medicare Medical Home Demo (cont.) Physician Eligibility

• Family practice, IM, geriatrics, general practice, and some specialty/subspecialty practices (CHCs are specifically included)

Patient Eligibility• Medicare Part A & B, FFS; Medicare as primary coverage

• Qualifying chronic disease

Site Selection• 8 sites, 50 practices per site = 400 practices total (approx. 2000 physicians)

• Geographic distribution; sufficiently large Medicare FFS population

• No other CMS demonstration projects in the area

• Preference given to: Medicare high cost areas and sites with private payer medical home demonstrations

Medicare Medical Home Demo (cont.) Monthly Medical Home Fees

• Tier 1 and Tier 2 – using revised version of NCQA PPC-PCMH• Adjusted using Hierarchal Condition Code (HCC) to reflect

severity and burden

Estimate that 25% of beneficiaries with HCC <1.6 and Medicare costs at least 60% higher than average

First 2% of savings not shared 80% of savings above 2% (minus fees) shared with

practicesPer Member per Month PaymentsHCC Score

<1.6HCC Score

>1.6Blended Rate

Tier 1 $27.12 $80.25 $40.40Tier 2 $35.48 $100.35 $51.70

More Information on PCMH Demonstration Projects

See the ACP website:http://www.acponline.org/running_practice/pcmh/demonstrations/index.html

Efforts Underway/the Future Multi-payer demonstration projects 2008 –

2010 and beyond (discussed earlier) Medicare Medical Home Demo 2010

(discussed earlier) Role of subspecialists/specialists* Support for practices* Facilitating coordination with other

providers and caregivers to provide optimal care

* Discussed further below

Efforts Underway/the Future Identifying common/recommended

evaluation metrics* Consumer organization projects aimed at

communicating PCMH to patients* Understanding/facilitating needed HIT* Educational reform for students/residents PCMH as part of broader health care

reform

* Discussed further below

Specialty Care Connections PCMH is NOT a gatekeeper system Jointly develop/identify referral guidelines Emphasis on transitions in care & continuity (e.g., referral

agreements, care transitions programs) Some subspecialists may want to qualify as PCMH; most will

likely prefer to be “neighbors” ACP in discussions with several groups regarding the PCMH

model and primary care/specialty care interface (sharing care)

ACP Council of Specialty Societies PCMH workgroup – has developed FAQs on the relationship of the PCMH to specialty physicians*

* FAQs available at: http://www.acponline.org/running_practice/pcmh/understanding/specialty_physicians.htm

Support for Practices ACP Medical Home BuilderSM - on-line

guidance for practices involved in incremental quality improvement changes - or significant transformation of their practices. Made up of 7 modules:• Patient-Centered Care & Communication • Access & Scheduling • Organization of Practice • Care Coordination & Transitions in Care • Use of Technology • Population Management • Quality Improvement & Performance Improvement

Additional information at: http://www.acponline.org/running_practice/pcmh/help.htm

Support for Practices (cont.) MedHomeInfo - A resource for physicians

and practices that want to participate in the Medicare Medical Home Demonstration.

Additional information at: http://www.medhomeinfo.org/

PCMH Evaluations/Metrics PCMH Evaluators Collaborative:

• Sponsored by The Commonwealth Fund• For researchers actively engaged in a

PCMH evaluation• Objectives:

Reach consensus about a standard set of data collection instruments

Reach consensus about a standard, core set of outcome measures

Share the Collaborative's consensus on instruments, metrics and/or methodological lessons with interested researchers around the country through public venues

Foster an ongoing and supportive exchange where evaluators share ideas that improve their evaluation designs

PCMH Evaluators Collaborative (cont.) Measurement workgroups will propose

standards for:• Patient experience• Physician/staff experience• Medical homeness• Clinical quality• Cost/efficiency• Process/implementation metrics

Proposed measure sets to be vetted with larger group of stakeholders

Additional information at: LINK TO BE ADDED

Consumer and Patient Information Introduction to the Patient-Centered Medical Home: A

multimedia program to explain the PCMH model to consumers. A collaboration between the Patient-Centered Primary Care Collaborative and Emmi Solutions®.

Merck Patient Education Brochure and Checklist: Developed for the PCPCC by Merck. in consultation with ACP and other organizations, to help health care professionals communicate with patients about the PCMH approach.

Primary Care: A Miracle of Modern Medicine: This brochure is a collaboration between Thomas Bodenheimer at the Center for Excellence in Primary Care at the Department of Family and Community Medicine at University of California, San Francisco; and the John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital.Links to these documents can be found at:

http://www.acponline.org/running_practice/pcmh/resources_tools/web.htmAdditional consumer materials can be found at:http://www.pcpcc.net

Consumer and Patient Information (cont.) National Partnership for Women and Families Medical

Home Principles: Developed by a broad coalition of more than 25 of the nation's leading consumer, labor, and health care advocacy groups to help health care providers, lawmakers, employers, and health plans consider consumer interests as they develop delivery system reforms such as the medical home.

Supporting Patient Engagement in the Patient-Centered Medical Home: White paper on patient engagement in the PCMH produced by the Center for the Advancement of Health. It includes a “Short Guide for Patients” and a sample “Patient-Clinician PACT”.

Creating a Patient Guide for a “Medical Home” Physician Practice: A resource by the Center for the Advancement of Health to assist medical home practices with creating a simple guide for their patients.

Links to these documents can be found at:http://www.acponline.org/running_practice/pcmh/resources_tools/web.htmAdditional consumer materials can be found at:http://www.pcpcc.net

Understanding/Facilitating Needed Health Information Technology Meaningful Connections: IT Resource

Guide• White paper by the PCPCC.

• Identifies the capabilities and functionalities of eHealth applications that experts consider crucial to support the PCMH.

• Available at: http://www.pcpcc.net/content/meaningful-connections-it-resource-guide

Now, there are some who question the scale of our ambitions, who suggest that our system cannot tolerate too many big plans. Their memories are short, for they have forgotten what this country has already done, what free men and women can achieve when imagination is joined to common purpose and necessity to courage.

What the cynics fail to understand is that the ground has shifted beneath them, that the stale political arguments that have consumed us for so long, no longer apply.

-President Barack Obama, January 20, 2009

Thank You!

Shari M. EricksonSenior Associate, Center for Practice Improvement &

InnovationDivision of Governmental Affairs & Public Policy

Washington, DCserickson@acponline.org

202-261-4551