1. Good Neighbors: How Will Medical Homes and the Rest of the Delivery System Relate to One Another? March 30, 2010 Hoangmai H. Pham Center for Studying Health System Change 1

2. Why look beyond medical homes? Fragmented delivery system Imperfect information systems Poorly aligned perceptions of patients’ interests and coordination responsibilities “Medical neighborhoods” as a bridge from here to accountable care entities

3. What PCMH, patients, and neighbors need to work on – together Achieve clarity on PCMH role in first-contact, longitudinal, comprehensive care Elicit, honor patient preferences Engage in effective, timely communication Synthesize information Facilitate and track receipt of needed services Engage in shared decision-making Formally assess performance Engage in systematic quality improvement

4. Reciprocity of responsibilities Symmetric – PCMH and neighbors each inform the other of changes to ongoing therapy Asymmetric – PCMH provides first-contact care, ensures access – Patients responsible for seeking first-contact care with PCMH, not “doctor shopping” – Neighbors re-direct patients seeking first-contact care to PCMH

5. Reliability of overlapping responsibilities PCMH has primary responsibility for eliciting and documenting patient’s care preferences Neighbors also help elicit and document care preferences

6. Designing Neighborhoods – Context Neighborhood emanates from PCMH No one size fits all Some PCMH’s could be led by subspecialists Not all neighbors are equal Neighborhoods should be compatible with FFS and bundled payments Avoid limiting patient choice Formalize expectations for PCMH and neighbors

7. Composition of neighborhoods Size, geographic reach Specialty mix among clinicians Institutional and community providers Not all neighbors are equal – “Core” neighbors and other neighbors

8. Entry into Neighborhoods Departs from health plan networks  PCMH selects neighbors with patient input Voluntary or mandatory Prospective or retrospective Overlapping or not Formal “care coordination agreements”

9. Accountability Positive and negative financial incentives Public reporting Patient volume Regulatory requirements for payment Reflect different contributions from neighbors

10. Neighborhoods and Accountable Care Organizations Negotiating “Bottom up” vs. “Top down” Protecting prominence of primary care Ensuring equitable governance Staying patient centered and population based Leveraging common resources 10

11. What the legislation says… About Medicare investments in medical homes and ACOs – Goals – Payment – Participation by primary care providers But can we accommodate short, tall, fat, thin? 11