The Medical Home and Physician Payment Reform Discussion Forum October 17, 2007 Debra Ness Co-Chair, Consumer-Purchaser Disclosure Project President, National Partnership for Women & Families Peter V. Lee Co-Chair, Consumer-Purchaser Disclosure Project CEO, Pacific Business Group on Health

© Consumer-Purchaser Disclosure Project, Agenda Welcome and Introductions The Patient Centered Medical Home: A New Model for Primary and Principal Care Patient-Centered Medical Home: Knowing When We See One Medical Home Demonstrations: –Rhode Island Experience –Private Health Plan –Medicare Pilots

© Consumer-Purchaser Disclosure Project, Medical Home Issues How will this impact patients/consumers? Will it make care better and more patient-centered? Or is this just another gatekeeper system? What are the critical essential elements? What are the potential pitfalls? Is this a positive step on the path to payment reform? What are the short and long term impacts on spending? How does this fit in the current context of the SGR debate?

© Consumer-Purchaser Disclosure Project, Coordination of Care and the Current “System”: A Mismatch Cure vs. care Single disease vs. comprehensive care Acute (short-term) vs. chronic (long-term) care Health care setting vs. continuous care approach Patient (dependent) vs. consumer (partner) centered

© Consumer-Purchaser Disclosure Project, System Failures Inconsistent medical management Inadequate transfer of information Poor communication Limited access to services Perceived lack of accountability Lack of systems to bridge transitions

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9 Context: Utilization in Medicare – Few People, Big Dollars

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© Consumer-Purchaser Disclosure Project, Private Insurance Making Bad Payments Worse – Rewarding Procedures over Care 2005 Medicare fee for CPT code 99214: 30 minute office visit2005 Medicare fee for CPT code 99214: 30 minute office visit –Relative value unit (RVU): 2.18 –Conversion factor: 37.9 –Fee 2.18 x 37.9 = $ Medicare fee for CPT code 45378: colonoscopy (30 minutes)2005 Medicare fee for CPT code 45378: colonoscopy (30 minutes) –RVU: 5.46 –Conversion factor: 37.9 –Fee 5.46 x 37.9 = $ private insurance fee for CPT code 45378: colonoscopy2005 private insurance fee for CPT code 45378: colonoscopy –RVU:5.46 –Conversion factor 45.5 (120% of Medicare) –Fee 5.46 x 45.5=$ Markets in which gastroenterologists are well organized: colonoscopy feeMarkets in which gastroenterologists are well organized: colonoscopy fee –RVU:5.46 –Conversion factor75.8 (200% of Medicare) –Fee 5.46 x 75.8=$ Adapted from T. Bodenheimer, M.D., UCSF, May 2006

© Consumer-Purchaser Disclosure Project, Medical Home Issues How will this impact patients/consumers? Will it make care better and more patient-centered? Or is this just another gatekeeper system? What are the critical essential elements? What are the potential pitfalls? Is this a positive step on the path to payment reform? What are the short and long term impacts on spending? How does this fit in the current context of the SGR debate?

© Consumer-Purchaser Disclosure Project, The Disclosure Project The Consumer-Purchaser Disclosure Project is a coalition of more than 50 of the nation’s leading consumer, labor, and employer organizations that is working to advance publicly reported, nationally standardized measures of clinical quality, efficiency, equity, and patient centeredness for health plans, hospitals, medical groups, physicians, other providers, and treatments. The Disclosure Project is supported by in-kind support of participating organizations and by financial support from The Robert Wood Johnson Foundation. For more information: