steven peskin grand rounds1 8 30 11
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Grand Rounds Jersey Shore Medical Center: Healthcare Reform, PCMHTRANSCRIPT
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Steven R Peskin, MD, MBA, FACP
EVP and Chief Medical Officer
MediMedia USA
Associate Clinical Professor of Medicine
Robert Wood Johnson Medical School
Grand Rounds Jersey Shore Medical Center
Road to Healthcare Reform, The Medical Home and ACOs
August 30, 2011
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Road to Healthcare Reform
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Health reform: early 20th century
1912: Theodore Roosevelt believed that no country could be strong whose people were sick and poor, campaigned on a platform that called for mandatory health insurance for workers
AMA originally supported universal coverage, but by 1920, many physicians viewed compulsory insurance as threat to private practice, paternalistic, and “un-American” and AMA House of Delegates voted to oppose.
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Health reform: mid 20th century
FDR spoke in favor of a right to medical care, but did not push compulsory HI over fear that it would endanger other Social Security reforms
Bill after bill introduced to mandate coverage, but none passed the Congress
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1945: Truman proposed a single plan to provide coverage for all age groups financed by 4% rise in Social Security payroll taxes
AMA raised $3.5 million to oppose the bill, calling it “regimentation” and “totalitarianism”—even though Truman had no chance of getting it through a GOP-controlled Congress
Health reform: mid-20th century
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Health reform: the 1960s
Kennedy campaigned for a comprehensive program of HI coverage for the elderly
AMA established AMPAC with goal of electing conservatives to Congress and opposing Medicare
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Health reform: the 1960s
Assassination of JFK and LBJ’s ascendancy changed everything; LBJ believed in Medicare even more than JFK and knew how to get legislation through Congress
1964 elections: LBJ trounced Goldwater and the Democrats gained a 2-1 majority in Congress
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Health reform: the 1960s
1965 Medicare and Medicaid passed, providing hospital and medical care for the elderly and creating a State/Federal partnership to cover the very poor
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Health reform: 1970s
Under Nixon, Medicare expanded to cover disabled, Wage and Price controls; beginning of limits on Medicare payments to physicians and hospitals, increased regulation of physicians and health care facilities
Nixon proposed mandatory employer-sponsored HI but didn’t pass Congress
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Health reform: 1970s
1976: Carter campaigns for catastrophic plan, but after election priority shifts to controlling health care costs
Sen. Kennedy offers new legislation for mandatory employer HI, government subsidies for poor, competition among private plans, and negotiated fees
Bills fail due to economic recession, rising health costs, Congressional committee restructuring, and failure of advocates for comprehensive coverage to compromise
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Health reform: 1980s
Reagan favored repeal of many of the regulatory laws passed in the previous decade (e.g., National Health Planning Act and PSRO program); market-based “pro-competition” approach and tax credits favored for expanding HI
Medicare catastrophic and prescription drug coverage enacted, but repealed as seniors objected to paying for it
Growth in budget deficits led to new methods of paying doctors and hospitals
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Health reform: 1990s
Rising health care costs and 46 million uninsured increased popular support for HI reform
Clinton administration became the first since Truman to pursue a comprehensive plan to provide universal coverage
Health Security Act called for mandated employer and individual coverage, managed competition, purchasing alliances, global budgets
Plan failed to pass congressional committees
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Health reform: late-1990s
Following defeat of Clinton plan, more modest goals were set for expanding coverage, including S-CHIP program for low-income children
GOP take-over of Congress led to enactment of Balanced Budget Act of 1997, which mandated cuts in payments to hospitals, physicians, other providers and new “Medicare+Choice” program—first step toward goal of privatizing Medicare
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Ironically, Republican Congress passed and President George W. Bush sign into law the largest expansion of federal entitlements since 1965: Medicare Prescription Drug Program (Part D)• Decision to run the program through private
insurers and PBMs put a conservative “stamp” on expansion of entitlements
• No dedicated funding or offsets, adding to federal deficit
Health reform: early 21st century
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Obama campaigned for universal health care coverage, 2008 elections returned the Democrats to the White House and solidified control over Congress
After 18 months of contentious debate, Congress passes health care reform in March, 2010
Health reform: the present
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Health reform: the present
March 22, 2010:
Almost 100 years after a U.S. President first proposed Health insurance for all, the Patient Protection and Affordable Care Act is signed into law
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ACA: Coverage
No pre-existing condition exclusions• Children (2010)
• Adults: Temporary high risk pool (2010), then all plans must cover (2014)
No rescissions (2011)
Up to age 26 covered by parents’ plan (2010)
Preventive services with no-cost sharing (2010 for new plans, 2014 for all HI)
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ACA: Coverage Medicare Part D doughnut hole:
$250 rebate (2010), 50% discount on brand name drugs (2011), to be completely phased out by 2020
Individual and small business tax credits applied to purchase of HI through state exchanges (2014)
Qualified health plans must offer basic benefits packages: bronze, silver, gold, platinum, plus low cost-plan for under age 30 (2014)
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ACA: Coverage
Large employers must pay a penalty if their employees obtain coverage through an exchange (2014)
Individuals required to buy coverage or pay penalty (2014)
Medicaid expanded to 133% of FPL with 100% of cost initially paid for by federal government (2014), phases down to 90%
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ACA: Coverage
When fully implemented, 34 million previously uninsured Americans will have coverage (94% of legal residents)• Half by HI offered through exchanges, half by
Medicaid
• But most Americans will continue to obtain coverage through employer-sponsored HI
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ACA: Workforce
Primary Care Incentive Program: 10% bonus for designated services by primary care physicians (2011-2015)
Medicaid primary care parity: states can pay no less than Medicare rates for visits and vaccines by primary care physicians (2013, 2014)
Workforce Commission (appointed 2011, not yet funded) to project workforce needs and addresses barriers to primary care
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ACA: Workforce
Unused residency slots redistributed to primary care (2011)
GME offered through Teaching Health Centers (2011)
NHSC: more slots for scholarships and loan forgiveness, higher maximum awards, and part-time awards (2011)
Community Health Centers (2011)
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ACA: Workforce
Title VII funding for primary care training programs, scholarships, faculty and curricula development (2011)
State workforce grants (2011)
State grants for primary care extension program (2011)
Grants for health teams to support smaller practices become PCMHs (2011)
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ACA: Cost and Quality
Center on Medicare and Medicaid Innovation (ongoing) • ACOs
• Bundling
• Other voluntary pilots to align incentives with value
• Must include models to reform primary care payments
Pay-for-performance (ongoing)
Review of Mis-valued services (ongoing)
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ACA: Cost and Quality
Insurers must spend at least 85% of premium dollar on direct patient care or pay a rebate (80% for small employers), 2011
Insurers will be required to streamline and reduce paperwork on patients and physicians, including enrollment, electronic funds transfers, and authorization requirements or pay a fine (rules to be rolled out starting in 2011)
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ACA: Cost and Quality
Patient-Centered Outcomes Research Institute (ongoing)
Wellness and prevention trust fund (ongoing)
National Quality Strategy (2011)
Employers may offer 50% premium discount for employees who achieve personal health goals (2014)
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How is the ACA funded?
Annual fee on health insurers and excise tax on high cost health plans
Excise tax on medical devices and fee on drug manufacturers
Tanning salon tax
Tax on earned/unearned income of higher wage persons
Pay cuts to hospitals, home health and MA plans
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Healthcare Reform and the Patient Centered
Medical Home
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The Need
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Need for a New Healthcare Delivery Model Increasing costs
• Healthcare costs are growing faster than the economy and the cost of care is becoming difficult for employers, government and individuals to meet.
Need to improve quality• Patients receiving recommended treatment 55 % of
the time
• Poor U.S. performance on healthcare benchmarks compared to other developed countries despite spending more.
Regional variation• Healthcare cost and quality vary substantially among
geographic regions. Little relationship between cost and quality.
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Need for a New Healthcare Delivery Model Inadequate response to chronic care
needs• Increasingly aging and chronically ill population
with payment system that doesn’t recognize services found necessary for essential care e.g. care coordination, evidence-based population management, disease self management
Decreased Interest in Primary Care• The number of new students entering into primary
care is decreasing and physicians who have chosen the field are disproportionately leaving compared to other specialties.
• Both domestic and international data indicating that higher proportion of primary care physicians related to higher healthcare quality and lower costs.
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Key Elements of Patient Centered Medical Home
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A Joint Proposed SolutionThe Patient-Centered Medical Home (PCMH)
Modern “medical home” concept originally in Pediatric literature in the 1960’s—a central source of care for “Special Needs” children.
AAFP—Future of Family Medicine Project (2004) “Personal Medical Home”
ACP—Advanced Medical Home (2006)
Key elements of a PCMH are described in a March 2007 joint statement of principles from ACP, AAFP, AAP and AOA. Often referred to as the “Joint Principles”.
Nexus of patient-centered care, primary care and chronic care model concepts
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The Patient-Centered Medical Home
Redesigns clinical delivery and payment to facilitate• Patient-centered, longitudinal, coordinated
care delivered by a “recognized” practice with a personal physician
• Who accepts responsibility for the patient’s “whole person”
• Who acts in partnership with patients and in collaboration with multidisciplinary teams (nurses, physician specialists, health educators, pharmacists)
• Who uses practice level systems to improve access and communication, care integration, patient safety and outcomes
• Who accepts accountability for care provided through on-going performance measurement and quality improvement.
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A New Model of Care that Redesignsthe Way Primary Care is Delivered and Financed
Patient Personal Physician
Trusted personal physician Physician who provides, manages and facilitates care Care is coordinated or integrated across healthcare
system
More accessible practice with increased hours and easier scheduling
Enhanced payment that recognizes the added value of delivering care through the PCMH model
Assistance to practices seeking transformation Support to practices adopting HIT for QI
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Not Defined by any Certain Specialty
Personal PhysicianPatient
v
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Physician as Facilitator, Not a Gatekeeper
Specialist Care Pharmacist Care
Hospital Care
Personal PhysicianPatient
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(5) Changes in Clinician Incentives
Fee For Service Fee for service
Prospective payment
Pay for outcomes
Blended Payment Improved Patient InteractionBetter Work Environment
Team effort
Increased responsibility for admin and clinicians
More time for patients
Better communication and access
Case management
Personal Physician
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PPC 1: Access & Communication (9)
PPC 2: Patient Tracking & Registry Functions (21)
PPC 3: Care Management (20)
PPC 4: Patient Self-Management Support (6)
PPC 5: Electronic Prescribing (8)
PPC 6: Test Tracking (13)
PPC 7: Referral Tracking (4)
PPC 8: Performance Reporting & Improvement (15)
PPC 9: Advanced Electronic Communication (4)
TOTAL POINTS: 100
Nine Core Components
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Demonstration Projects
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(Patient Centered Medical Home)
6% decrease in hospital admissions
24 % decrease emergency room
$500, Per member per years savings
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Horizon Blue Cross Blue Shield/Partners In Care
For the New Jersey State Health Benefits Program
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Results: Clinical Process Metric Improvement
HbA1c Testing
January 2007
November2007
Permission from Horizon Blue Cross Blue Shield and Partners in Care, Corp.
91%
43%0
25
50
75
100
January 2007
November2007
HbA1c Testing
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Lewisburg Pennsylvania
preTest period Jan - Oct 2006
First pilot year Jan – Oct 2007
Percent reduction
Hospital Admission
365/1000 291/1000 -20%
Hospital readmissions
15.2% 7.9% -48%
Cost 7% less
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9%
4%
22%
13%
0%
5%
10%
15%
20%
25%
Year 1 Year 2 Year 3 Year 4 Year 4.5
Hospitalization E.R. Visit
Marillac’s Integrated Care Patients (PCMH)
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Overview of PCMH Commercial
Pilot Activity
• 22 projects• 16 states
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Overview of PCMH Commercial
Pilot Activity (cont.)Since October 2008:• Alabama• California• Indiana• Maryland• North Carolina• Oklahoma• Oregon• West Virginia
New commercial
PCMH projects under development in at least 8 more states:
Additionally, new projects are under development in the previous states, such as Colorado (Family Medicine Residency Program), Michigan (Priority Health), and Tennessee (BCBS-TN)
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= 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
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Combined Medical Home Activity
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Healthcare Reform: Accountable Care
Organizations
Three models involve a retrospective bundled payment arrangement, and one model would pay providers prospectively
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Accountable Care Organizations
“…consist of providers who are jointly held accountable for achieving measured quality improvements and reductions in the rate of spending growth.” ¹
MEDPAC Explanation: “…a group of physicians teamed with a hospital would have joint responsibility for the quality and cost of care provided to a large Medicare patient population…Potential ACOs include: integrated delivery systems, physician–hospital organizations, a hospital plus multispecialty groups, and a hospital teamed with independent practices.” ²¹McClellan et al: Health Affairs, May 2010
²MEDPAC June 2009 report
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PatientPhysician Practice Team
Physician Practice Team
Physician
Practice Team
Physician
Practice Team
Integrated Delivery System
Accountable Care Organization
Clinical Integration IndependentPractice Assoc.
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Provider Organizations That Can Become ACOs
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ACO Payment Options
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Three models involve a retrospective bundled payment arrangement, and one model would pay providers prospectively
U.S. Encourages Bundling Medicare Payments
The Centers for Medicare and Medicaid invited providers on Tuesday to help develop four models to bundle payments as part of a larger effort to improve patient care and reduce costs.
The program is meant to encourage hospitals, doctors and other specialists to coordinate in treating a patient's specific condition during a single hospital stay and recovery.
The four models give providers flexibility on how they get paid and for which services, as well as give them financial incentives to avoid unnecessary or duplicative procedures. Three models involve a retrospective bundled payment arrangement, and one model would pay providers prospectively
Applicants for these models would also decide whether to define the episode of care as the acute care hospital stay only (Model 1), the acute care hospital stay plus post-acute care associated with the stay (Model 2), or just the post-acute care, beginning with the initiation of post-acute care services after discharge from an acute inpatient stay (Model 3). Under the fourth model, CMS would make a single, prospective bundled payment that would encompass all services furnished during an inpatient stay by the hospital, physicians and other practitioners.
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7 Core ACO Competencies and Associated Critical Success Factors
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7 Core ACO Competencies and Associated Critical Success Factors
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Thank You!
Discussion
Three models involve a retrospective bundled payment arrangement, and one model would pay providers prospectively