1. Patient-Centered Medical Homes
Ira B. Wilson
March 3, 2014

2. Notes
Keep an eye on In the News: several very interesting and relevant articles
Next test is coming soon (March 19th): don’t take a break and try to catch up
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5. Goals Primary Care Pipeline The ACA and Primary Care
Patient Centered Medical Homes
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6. The Pipeline
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Bodenheimer. NEJM 2006;355:

8. 2010 Residency Match Data
COGME 20th Report, Advancing Primary Care, 2010
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9. International Medical Graduates
In 2005 and 2006, about 25% of office visits were to international medical graduates (IMGs)
57% of IMGs were in primary care specialties, compared with 46.2% of US medical graduates
Outside of metropolitan areas, 67.8% of IMGs, compared with 39.8% of US graduates, practiced in areas with primary care shortages
In 2009, 2/5 of first-year residents in primary care were IMGs
Steinbrook. NEJM 2009;360:
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10. Who is Going Into Primary Care?
Bodenheimer. NEJM 2006;355:
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11. Steinbrook. NEJM 2009;360:
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12. Steinbrook. NEJM 2009;360:
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13. Take Home Points Not much of a pipeline Demand far exceeds supply
Primary care is attracting FMGs reflecting that it is a lower demand, lower status segment of the market
Note that some specialists can do Primary Care (e.g., internal medicine and pediatrics)
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14. The ACA and Primary Care

15. ACA and Primary Care
Medicare 10% increase in primary care reimbursement rates, 2011–2016 ($3.5 billion)
Medicaid reimbursement for primary care increased to at least Medicare levels, 2013–2014 ($8.3 billion)
15-20M (?) more people insured, with preventive and primary care coverage, leading to less uncompensated care
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16. ACA and Primary Care
Medicare and Medicaid patient-centered medical home pilots
Grants/contracts to support medical homes through
Community Health Teams increasing access to coordinated care
Community-based collaborative care networks for low-income populations
Primary Care Extension Center program providing technical assistance to primary care providers
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17. ACA and Primary Care
Scholarships, loan repayment, and training demonstration programs to invest in primary care physicians, midlevel providers, and community providers
$11 billion for Federally Qualified Health Centers, 2011–2015, to serve 15 million to 20 million more patients by 2015
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18. M. K. Abrams et al. Realizing Health Reform’s Potential: How the Affordable Care Act Will Strengthen Primary Care and Benefit Patients, Providers, and Payers, The Commonwealth Fund, Jan. 2011
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20. Details
Train 13,000 primary care residents in high-need communities ($5.23 billion over 10 years)
Extends higher payments to Medicaid providers, including physician assistants and nurse practitioners, by one year ($5.44 billion)
Enlarge National Health Services Corps from 8,900 primary care providers in 2013 to at least 15,000 annually ($3.95 billion over next six years)
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21. Take Home Points
The ACA does a number of things to promote primary care
Impact of these interventions remains to be seen; good ideas, relatively small dollars
Biggest impact may be related to ACOs (more on this 4/14)
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22. Patient-Centered Medical Homes

23. PCHM Goals What are PCMHs? How are they different?
How are they working so far?
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24. Required Reading
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25. What Needs to be Improved?
Access
Cost
Quality
Patient experience
Provider experience
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26. What Needs to be Improved?
Access
Cost
Quality
Patient experience
Provider experience
Be developing your on list of problems and potential solutions
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27. Principles of PCMHs Personal physician
Physician directed medical practice
Whole person orientation
Care is coordinated and/or integrated
Quality and safety ensured
Enhanced access
Payment reform
From: Joint Principles of the Patient-Centered Medical Home, Jan 2007
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28. Primary Care Physician Groups
“Joint” means endorsed by the 4 main physician groups interested in primary care
American Academy of Family Physicians
American Academy of Pediatrics
American College of Physicians
American Osteopathic Association
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29. Personal Physician
Each patient has an ongoing relationship with a personal physician trained to provide first contact, and continuous and comprehensive care
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30. Physician Directed Medical Practice
The personal physician leads a team of individuals who collectively take responsibility for the ongoing care of each patient
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31. Whole Person Orientation
The personal physician is responsible for providing all the patient’s health care needs and organizes needed referrals
This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care
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32. Coordination/Integration
Coordination across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services)
Care is facilitated by registries, information technology, health information exchanges and other means
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33. Quality and Safety in Ensured
Evidence-based medicine and clinical decision-support tools guide decision making
Physicians engage in performance measurement and improvement activities
Information technology supports patient care, performance measurement, patient education, and enhanced communication
Patients and families participate in quality improvement activities at the practice level
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34. Enhanced Access Implement systems such as
Open scheduling (facilitating same day appointments)
Expanded hours: evenings and weekends
New options for communication between patients, their personal physician, and practice staff (e.g., , patient portals)
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35. Payment Reforms
Reflect work/thought that falls outside of the face-to-face visit
Pay for coordination of care both within a given practice and between consultants and other resources
Support adoption and use of health information technology for quality improvement
Support enhanced communication access such as secure and telephone consultation
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36. Impact on Physician Work Life?
One-on-one vs. team care
Participant/leader in team care
Interdisciplinary teams that might include nurses, patient educators, pharmacists, care coordinators, and others
Enhanced coordination and collaboration with other care settings
Patients/families as partners
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37. NCQA* Certification Three levels of certification
1: points and all must pass elements
2: points and all must pass elements
3: points and all must pass elements
* National Committee for Quality Assurance
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38. Six NCQA Standards Enhance access and continuity
Identify and manage patient populations
Plan and manage care
Provide self-care and community support
Track and coordinate care
Measure and improve performance
Combinations of these attributes give you points toward the levels
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39. Details: http://www. ncqa
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40. Results to Date Anecdotal reports of dramatic improvements
Formal, peer reviewed, evaluations are accumulating slowly
Results mixed so far
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42. Why Important
Large: 32 intervention and 29 control practices and 120K patients
Multipayer: 6 payers involved
Duration: 3 years
Evaluation included
Structural changes
Quality improvements
Utilization and cost outcomes
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44. Accompanying Editorial
“One Size Does not Fit All”
Think of PCHM intervention as a high cost technology
Focus should be on high risk, high cost subset of patients; those with multiple chronic conditions
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45. Interpreting Mixed Results
Goal: achieve the Triple Aim*
Improving the experience of care
Improving the health of populations
Reducing per capita costs of health care
* Berwick et al., The Triple Aim; Care, Health, Cost. Health Affairs, May 2008, vol 27, no. 3,
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46. Interpreting Mixed Results
Goal: achieve the Triple Aim*
Significant internal challenges
Changing daily activities
Changing how providers in PCMH’s communicate with each other
Integrating new people and new roles into primary care practices (e.g. care coordinators)
Requires new skills
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47. Interpreting Mixed Results
Goal: achieve the Triple Aim*
Significant internal challenges
Significant challenges relating key external parties
Specialists
Hospitals
Rehabilitation and skilled nursing facilities
Home health practitioners
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48. Interpreting Mixed Results
Goal: achieve the Triple Aim*
Significant internal challenges
Significant challenges relating key external parties
Real and lasting culture change is slow and difficult
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49. Interpreting Mixed Results
Goal: achieve the Triple Aim*
Significant internal challenges
Significant challenges relating key external parties
Real and lasting culture change is slow and difficult
Patients and families have to change also!
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50. Required Reading
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51. Larson and Reid
2002 to efforts to improve access, change reimbursement models, increase productivity -> physicians didn’t like it
2006 pilot to decrease panel size and increase visit length -> better response
Unclear how this will roll out to other clinics
They conclude that primary care is complex and difficult, and change is hard (even in an organization like theirs)
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52. Non-required reading
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53. Take Home Messages
We need more primary care providers and a more primary care oriented health care system
We also need to reinvent primary care practice so that it
Produces better results for patients
Is a higher quality work environment for providers
PCMH’s: important, promising new model; not simple to implement; no magic bullet
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54. Summary of Arguments: Primary Care
Value proposition: can be improved with a more primary care oriented health care system
NB: specialty care is critical – the issue is how do we get the proportions right
Does the primary care have it’s act together? NO!
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