Jim Stout, MD, MPH A. Chris Olson, MD, MHPA Professor of Pediatrics President University of Washington Washington Chapter of the AAP Clinical Professor University of Washington 1

 Value of Primary Care  Medical Home Model  Care Coordination  Family-Centered Care  Quality Improvement 2

 Undervaluing E&M Codes predominately provided by PCP’S  RVU’s determinations that overvalue some services/procedures to the detriment of other services in Medicare’s budget neutral system  Not paying for those services required to allow the PCP to provide patient-focused, longitudinal, coordinated care. 3

 Cuts to reimbursement that disproportionately adversely impact primary care physicians  Providing incentives for volume of services with no regard to the quality or efficiency of the clinical service provided 4

 “The collapse of primary care will result in our health care system becoming increasingly fragmented, over-specialized, and inefficient – and lead to poorer quality, higher costs, reduced access, and increased patient dissatisfaction.” Reform of the Dysfunctional Healthcare Payment and Delivery System American College of Physicians, A position paper

 States with higher ratios of primary care to specialty care have better health outcomes.  Areas with more specialists have higher per captia Medicare spending  Increase in primary care physicians is associated with a significant increase in quality of health services, as well as a reduction in costs. 6

 Cross national comparisons indicate that nations with stronger primary care infrastructures have lower rates of premature births, deaths form treatable conditions, and post neonatal mortality.  Studies have repeatedly demonstrated that the vast majority of Americans prefer a sustained relationship with a primary care provider. 7

 Primary care oriented countries achieve notably better outcomes for health in early childhood: low birth weight rations, postneonatal mortality, infant mortality, and child mortality, including deaths from injury. 8

 The American Academy of Family Physicians believes that everyone should have a personal medical home that serves as the focal point through which all individuals-regardless of age, sex, race, or socioeconomic status-receive acute, chronic, and preventive medical services. Through an on-going relationship with a family physician in their medical home, patients can be assured of care that is not only accessible but also accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians. (May Board 2006) 9

 “Attributes of the advanced medical home include promotion of continuous healing relationships through delivery of care in a variety of care settings according to the needs of the patient and skills of the medical provider. Physicians are once again partners in coordinating and facilitating care to help patients navigate the complex and often confusing health care system by providing guidance, insight and advice in language that is informative and specific to patients’ needs.” 10

 Increased patient and family satisfaction  Establishment of a forum for problem solving  Improved coordination of care  Enhanced efficiency for children, youth, and families  Efficient use of limited resources  Increased professional satisfaction  Increased wellness resulting from comprehensive care  Provide a basis for quality improvement in the care of children and families 11

12 What is a Medical Home? NOT just a building or place but a way of providing health care services that are: Accessible Family-centered Coordinated Comprehensive Continuous Compassionate Culturally Sensitive

 Personal physician vs. team of providers  Care Coordination  Quality and Safety ◦ “Physician in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement” 13

 Payment Discussion ◦ Recognizes the added value provided to patients who have a patient-center medical home. ◦ Recognize case mix differences in the patient population ◦ Separate fee-for-service payments for face to face and other management services ie. Care coordination 14

 Primary care is on the verge of collapse  Very few young physician are going into primary care (EROAD)  There will not be enough primary care physicians to take care of an aging population with growing incidences of chronic diseases  Without primary care, the health care system will become increasingly fragmented, over specialized, and inefficient. Leading to poorer quality care at higher costs  When compared with other developed countries, the United States ranked lowest in its primary care functions and lowest in health care outcomes, yet highest in health care spending. 15

 The Secretary shall establish a medical home demonstration project to redesign the health care delivery system to provide targeted, accessible, continuous and coordinated, family- centered care to high-need populations and – ◦ Care management fees are paid to personal physicians ◦ Incentive payments are paid to physicians participating in practices that provide a medical home  “High-need population” means individuals with multiple chronic illnesses 16

 Medical Home Demonstration project tied to SCHIP reauthorization  Demonstration Project Aims ◦ Increase cost efficiency ◦ Increase access to appropriate services ◦ Increase patient satisfaction ◦ Decrease inappropriate ED utilization ◦ Decrease service duplication 17

 Provide appropriate preventive care  Provide appropriate referrals to multidisciplinary services  Increase school attendance  Increase agreed upon measures of quality 18

 Implementation phase  Practice Change Principles  Family involvement in practice change  Increases interest in practice 20

21 Changing a pediatric practice is like trying to change the tire on a bicycle while you are riding it

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 Implementation phase  Practice Change Principles  Family involvement in practice change  Increases interest in practice 24 Quality Improvement

KnowledgePersuasionDecisionImplementationConfirmation

Late Majority Early Majority Early Adopters Traditionalists Innovators 2% 13%35% 15%

Year Number of Farmers in Communities Source: Based on Ryan and Gross (1943). Cumulative Number of Adopters

Expert Planning Group Meeting Refine Collaborative Design Change Concepts Participants LS 1 LS2 (Oct) LS 3 (March) Phone Assessments Supports Visits Documents Prework P S A D P S A D Action Period 2 Action Period 3 Action Period 1 Closeout Institute for Healthcare Improvement P S A D We are here

 Union Avenue Pediatrics/ Neurobehavioral Assoc.  Swedish Children's Clinic  Ida Karlin Pediatrics  Virginia Mason Sand Point Pediatrics  SW Washington Medical Center (Vancouver) Healthy Steps

 International Community Health Services  Swedish Children's Clinic  Ida Karlin Pediatrics  Columbia Basin Health Assoc.  Polyclinic Pediatrics  Group Health - Tacoma South Pediatrics

 Valley Family Medicine  Skagit Pediatrics  CMCC/Mary Bridge Children's Health Center  Odessa Brown Children's Clinic  Eastgate Public Health Center  Northwest Pediatric Center, Inc.  Virginia Mason Sand Point Pediatrics  Polyclinic Pediatrics

Expert Planning Group Meeting Refine Collaborative Design Change Concepts Participants LS 1 LS2 (Oct) LS 3 (March) Phone Assessments Supports Visits Documents Prework P S A D P S A D Action Period 2 Action Period 3 Action Period 1 Closeout Institute for Healthcare Improvement P S A D We are here

“Impedimento non mi piega” Leonardo daVinci

 Raises eligibility to 250% of poverty (Family of four $50,000) and in 2009 to 300% poverty  Funding for outreach  Increase reimbursement to providers  Quality measures ◦ “Shall identify explicit performance measures that indicate that a child has an established and effective medical home” ◦ Such as  Vaccine rates  Well child care utilization 46

 Care management of children with chronic illnesses  Emergency room utilization  Preventive oral health service utilization  Report by December 2007  Reimbursement in 2009 related to measurements of quality 47

 Value of medical home concept in developing case for primary care ◦ Ability to frame the issue of increasing access to a medical home is good for the state and the families ◦ Financial realities of the small businesses that provide the medical home for families ◦ Great to have insurance but if no provider can afford to see patients, insurance alone won’t solve the problem.  Governor’s agenda  Legislative agenda  Relationships 48

 What has been your experience in promoting medical home?  What tools do you need to implement medical home in your practice, your community of physicians?  What are your barriers to implementation and quality measures? 49