the patient centered medical home (pcmh) activities, findings, and challenges 15 th annual nhma...

The Patient Centered Medical Home (PCMH) Activities, Findings,

and Challenges

15th Annual NHMA ConferenceMarch 19, 2011Shari M. Erickson, MPH

Director, Regulatory and Insurer Affairs

Presentation Outline

Joint Principles

Specialty Care

Connections

PCMH Recogniti

on programs

Efforts to test the PCMH model

PCMH Evaluatio

ns & Results

ACP, AAFP, AAP, and AOA Joint Principles of the PCMH

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…

SOURCE: http://www.acponline.org/running_practice/pcmh/demonstrations/jointprinc_05_17.pdf (March 2007)

“Neighbors” Endorsing the Joint Principles

American Academy of Hospice and

Palliative Medicine

American Academy of Neurology

American College of

Cardiology

American College of

Chest Physicians

American College of

Osteopathic Family

Physicians

American College of

Osteopathic Internists

American Geriatrics Society

American Medical

Association

American Medical

Directors Association

American Society of Addiction Medicine

American Society of Clinical

Oncology

Association of Professors of

Medicine

Association of Program

Directors in Internal Medicine

Clerkship Directors in

Internal Medicine

Infectious Diseases Society of America

Society for Adolescent Medicine

Society of Critical Care

Medicine

Society of General Internal Medicine

The Endocrine

Society


Joint Principles

Specialty Care

Connections

PCMH Recogniti

on programs

Efforts to test the PCMH model

PCMH Evaluatio

ns & Results

Complex Delivery

Health care delivery is complex – e.g., the typical primary care physician coordinates care with 229 other physicians working in 117 practicesH H Pham, et al Ann Intern Med. 2009;150:236-242

Nearly Half of U.S. Adults Report Failures to Coordinate Care

Percent U.S. adults reported in past two years:

No one contacted you about test results, or you had to call

repeatedly to get results

Test results/medical records were not available at the time of appointment

Your primary care doctor did not receive a report back from a specialist

Any of the above

25

21

19

15

13

47

0 20 40 60

Doctors failed to provide important medical information to other doctors

or nurses you think should have it

Your specialist did not receive basic medical information from your

primary care doctor

Source: S. K. H. How, A. Shih, J. Lau, and C. Schoen, Public Views on U.S. Health System Organization: A Call for New Directions (New York: The Commonwealth Fund, Aug. 2008).

PCMH Neighbor Model

Proposes a Framework for Interactions between PCMH practices and Specialty Practices:• A scaffolding upon which Care

Integration and Information Exchange can be built

• Restore Professional Interactions for Patient Centered Care

• Improve Care Transfers and Transitions to enhance Safety and Stewardship/ reduce wasted resources

ACP-CSS Workgroup Policy Paper available at: http://www.acponline.org/advocacy/where_we_stand/policy/pcmh_neighbors.pdf

PCMH Neighbor Model (cont.)Defines concept of PCMH-N practices as practices that:• Communicate, coordinate and integrate

bidirectionally with PCMH• Ensure appropriate and timely consultations

and referrals• Ensure effective flow of information;• Address issues of responsibility in co-

management situations;• Support patient-centered care• Support the PCMH practice as the provider of

whole person primary care to the patient


PCMH Neighbor Model: How Does It Work?Via Care Coordination Agreements, which promote better communication and care coordination by defining:• Types of Interactions• Pre-consultation exchange to expedite/ prioritize

care• Consultation /procedure• Comanagement• Shared care• Principal care

• Responsibility for the elements of care• Expectations for information exchange


Additional Considerations for the PCMH Neighbor Model:

Incentives (both nonfinancial and financial) should be aligned with the efforts and contributions of the PCMH-N practice to collaborate with the PCMH practice.

A PCMH-N recognition process should be explored.


The PCMH Model and Accountable Care Organizations (ACOs)

The PCMH, in conjunction with the health care “neighborhood” in which it resides, is a critical foundation of ACOs

Source: Premier Healthcare Alliance

Support for Primary Care Foundation for ACOs“Some experts have advocated requiring a strong primary care foundation for Accountable Care Organizations (ACOs). Please indicate the degree to which you support or oppose establishing

standards for primary care capacity as a condition for qualifying for ACO payment.”

Strongly support

46%

Strongly oppose

2%

Support31%

Neither support nor oppose

12%

Oppose7%

Not sure1%

* Percentages may not be equal to 100 percent because of rounding.Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, July 2010.


Joint Principles

Specialty Care

Connections

PCMH Recognition

programs

Efforts to test the PCMH

model

PCMH Evaluations &

Results

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

Recognized PCMHs also must be accountable for quality of care by reporting on evidence-based clinical and patient experience measures—provides retrospective assurance

National Committee on Quality Assurance (NCQA) released the PPC-PCMH in January 2008; Revised version released in January 2011

Other entities are also developing or implementing PCMH recognition/accreditation processes – AAAHC, The Joint Commission, URAC

Guidelines for PCMH Recognition and Accreditation ProgramsThe AAFP, AAP, ACP, and AOA released these Guidelines in March 2011 to assist with the development and use of these programs.• Incorporate the Joint Principles of the Patient-Centered

Medical Home• Address the Complete Scope of Primary Care Services

(including comprehensive, whole person care)• Ensure the Incorporation of Patient and Family-Centered

Care Emphasizing Engagement of Patients, their Families, and their Caregivers

• Engage Multiple Stakeholders in the Development and Implementation of the Program

• Align Standards, Elements, Characteristics, and/or Measures with Meaningful Use Requirements

• Identify Essential Standards, Elements, and CharacteristicsThese Guidelines state that all Patient-Centered Medical Home Recognition or Accreditation Programs should:

Joint Guidelines for PCMH Recognition and Accreditation Programs available at: http://www.acponline.org/running_practice/pcmh/understanding/guidelines_pcmh.pdf

Guidelines for PCMH Recognition and Accreditation Programs (cont.)

All Patient-Centered Medical Home Recognition or Accreditation Programs should:• Address the Core Concept of Continuous Improvement that is

Central to the PCMH Model• Allow for Innovative Ideas• Acknowledge Care Coordination within the Medical

Neighborhood• Clearly Identify PCMH Recognition or Accreditation

Requirements for Training Programs• Ensure Transparency in Program Structure and Scoring• Apply Reasonable Documentation/Data Collection

Requirements• Conduct Evaluations of the Program’s Effectiveness and

Implement Improvements Over TimeJoint Guidelines for PCMH Recognition and Accreditation Programs available at: http://www.acponline.org/running_practice/pcmh/understanding/guidelines_pcmh.pdf


Joint Principles

Specialty Care

Connections

PCMH Recognition

programs


model

PCMH Evaluations &

Results

= Identified to have at least one private payer medical home pilot under development or underway

Overview of PCMH Commercial Pilot Activity (cont.)*

* As tracked by the American College of Physicians and the Patient-Centered Primary Care Collaborative (updated March 2011)

Initiatives to Advance Medical Homes in Medicaid/ CHIP

= Identified to have a Medicaid and/or CHIP medical home initiative underway or under development

Source: National Academy for State Health Policy (NASHP) State Map (http://nashp.org/med-home-map), March 2011

Medicare Multi-Payer Advanced Primary Care Initiative States

= States participating in the Medicare Multi-Payer Advanced Primary Care Initiative

Source: CMS, March 2011 (http://www.cms.gov/demoprojectsevalrpts/md/itemdetail.asp?itemid=cms1230016)

Combined Commercial, Medicaid/CHIP, and Medicare FFS PCMH Activity

= Identified to have at least one private payer medical home pilot under development or underway

= Identified to have a Medicaid and/or CHIP medical home initiative

= Identified to have both a private payer and a Medicaid and/or CHIP medical home initiative

* As tracked by the American College of Physicians (updated March 2011)

= Identified as a Medicare APC State, which includes private payers, Medicaid and/or CHIP, and Medicare FFS

More Information on PCMH Demonstration Projects

OR the PCPCC website:http://pcpcc.net/See the ACP website:

http://www.acponline.org/running_practice/pcmh/demonstrations/index.html

http://pcpcc.net/





Joint Principles

Specialty Care

Connections

PCMH Recognition

programs


model

PCMH Evaluations &

Results

PCMH Evaluations

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?

Community Implications - Results of PCMH Projects to Date (Integrated Systems)

Group Health Cooperative of Puget Sound

• 29% reduction in ER visits; 16% reduction in hospital admissions• $10 PMPM reduction in total costs• Improvements in diabetes and heart disease care• Greater staff satisfaction; less burnout; improved primary care recruitment and retention

Geisinger Health System

• 18% reduction in hospital admissions• 7 % reduction in total PMPM costs• Improvements in preventive, diabetes, and heart disease care• ROI greater than 2 to 1

Source: PCPCC Outcomes of Implementing PCMH Interventions (November 2010) - http://www.pcpcc.net/content/pcmh-outcome-evidence-quality

Community Implications –Results of PCMH Projects (Private Payer Sponsored)

BCBS of South Carolina-Palmetto

• 36% fewer hospital days and 32% fewer ED visits among PCMH patients when compared with control patients

• 6.5% reduction in total medical costs for PCMH vs. control

Metropolitan Health Networks-Humana (FL)

• 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 PCMH group compared to an increase of 17.4% for the control group


Community Implications – Results of PCMH Projects (Medicaid Sponsored)

Colorado Medicaid and SCHIP

• Median annual costs $785 vs $1000 in controls

• Reduction in ER visits & hospitalizations• More well-child visits (72% vs 27% in

controls)• Lower median costs for children with

chronic conditions ($2,275 versus $3,404 in controls)


More Results…

PCPCC Evidence Summary

And on the PCPCC website…www.pcpcc.net

http://www.pcpcc.net/content/evidence-guide-cover

Some Challenges and Questions for PCMH Going ForwardIs the PCMH model sustainable over the longer term?

What does it cost – to practices, payers, purchasers, and others?

Is the PCMH Neighborhood model achievable and can appropriate incentives be put into place effectively?What role should the PCMH and PCMH Neighborhood play in the development of ACOs?How will other payment and delivery system reform efforts impact the development of the PCMH model?Will the PCMH model have a positive impact on recruitment and retention of the primary care workforce?How do we more fully engage employers and consumers in the model?

How do we best understand and facilitate the necessary health IT?

Can the model be effectively integrated into medical education?

Thank You!

Shari M. Erickson, MPHDirector

Regulatory and Insurer [email protected]

202-261-4551

Questions?

mailto:[email protected]

the patient centered medical home (pcmh) activities, findings, and challenges 15 th annual nhma...

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