1. Patient-Centered Medical Home An Educational and Practice Challenge
New Mexico Medical Society
July 17, 2009
I guess my point is that it is crucial at the outset to affirm primary care as evidence based, but not feel like this presentation has to make that case in detail.
The pictorials of data flow are very helpful—and I’m wondering if there is one that actually puts the patient in the center, like some of the material up on the Markel Foundation website about the personal health record??  And this presentation may want to acknowledge the inevitability of the Personal Health Record maintained by individuals and of potential importance in care and measurement as it evolves.
One of my persistent requests of all sorts of presenters is to bring the word INTEGRATION into the discussion—not just the comprehensive, continuing, coordinated language.  Webster defines integration as the pulling together of what often appear to be disparate parts into a coherent whole that has meaning.  The PCMH’s fundamental function is the integration of care in a way that is meaningful to the patient and the health care system.  It is also a key work in the IOM definition of primary care and probably worth some attention up front.

2. Overview of Presentation
Driving forces behind Patient Centered Medical Home
Origins of Medical Home
Need for qualification and evaluation of PCMH
Development of PPC-PCMH
Beyond measurement: the challenge to Education and Practice
What is needed for the medical home to succeed?
The challenge to educational groups at all levels

3. Why do we need a “new” system (some would say we don’t have one now)
Costs have (for 50 years), and continue to, rise faster than GDP
Uninsured, underinsured and related issues
Can’t improve access without controlling costs
Major variation in costs WITHOUT relationship to quality (national/international)
Major gaps in quality
Hospital deaths and readmissions
In ambulatory care-about 50/50 chance of getting needed services

4. Primary Care Has Changed….Negatively
Increasing need for PCPs
Population age 85 and over will increase 50% from 2000 to 2010
Aging population means an increase in care for complex and chronic medical conditions
Decreasing number of PCPs
Projected shortage of 200,000 PCPs by 2020
Plunging interest in primary care
Entering internal medicine residents down to 10 % in 2008 from 54% in 1998.
Family Medicine: not filling residencies and high proportion filled by non US medical graduates
Primary care physicians are overworked and dissatisfied
Compensation is bottom of pay scale for physicians

5. Median Compensation for Selected Medical Specialties
Data are from the Medical Group Management Association Physician Compensation and Production Survey, 1998 and 2005

6. Yet Primary Care Leads to Better Quality and Lower Costs
Higher ratio of PCPs to specialists is associated with improved health outcomes and lower costs (Starfield-both international and within US data)
Adding 1 family practitioner per 10,000 people associated with 70 fewer deaths per 100,000 (9% reduction in mortality) and lower costs (fewer ambulatory sensitive admissions)
Specialists practicing outside their specialty area leads to an increase in mortality and cost (Fisher)

7. Impact of Primary Care Decline
Patients are dissatisfied and so are doctors
Patients can’t get timely access to acute care
Inability of patients to get timely appointment was 23% in 1997 and rose to 33% in 2005
Physicians hampered in provision of comprehensive chronic care
Lack time and state-of-the-art systems and processes (the hamster on a treadmill effect)
Pay for procedures- no compensation for nearly 25% of work that occurs between visits, for quality or efficiency
Gaming rather than value (procedure hobbies that reimburse well versus counseling)

8. Key Steps to a true “Health Care System”
Primary Care Patient Centered Medical Home as key building block
Implementation and use of health information technology and care systems at all levels of health care
Integration of care (real or virtual)
Reimbursement linked to desired process and outcomes of care (pay for what you want)
Measurement and feedback to determine if you are getting where you want to be

9. The Current Model of Care: Connection by Billing

10. The Current Model of Care: Connection by Billing

11. Future Model of Care: Step II Patient Centered “Medical Neighborhood”
Hospital
Sub-specialty “Medical Home Neighbor”
Sub-Specialty Procedural Practice
Patient-Centered
Medical Home
Data Center
Insurer

12. Patient Centered Medical Home A blending of concepts and critical building block for health system change

13. The Medical Home “Defined” ACP, AAFP, AAP, AOA
Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.
Care is coordinated and/or integrated 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 exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

14. The Patient Centered Medical Home is a journey not a destination “In transforming one's practice there is no "there there". There is no moment when the work is completely done. Those who think that the ultimate goal is achieving NCQA recognition will be disappointed. The goal is continuous transformation. Those practices who have a strong internal culture, a capacity to change, a sense of excitement and a perpetual ability to critically examine their own practices are best suited for this new environment.”

15. Primary Care Multiple formulations from 1960’s on Core concepts of
First contact
Coordinated
Comprehensive
Continuous
Strong empiric base linking primary care to higher quality and lower cost (within US and international)

16. Wagner Model for Effective Prevention and Chronic Illness Care

17. Wagner Model Chronic (Planned) Care Model
Formulated in 1980’s but with prior roots in primary care and elsewhere
Based on varying amounts of empiric evidence (qualitative to RCT’s)
Since developed, multiple studies evaluating model and components of the model (
Successful application to both chronic and preventive care (thus “planned care”)
Empiric basis bolstered by Shortell work on systems and quality

18. Patient Centeredness Studies and formulations funded and led by Picker
Defined in “Crossing the Quality Chasm by IOM “the system of care should revolve around the patient, respect patient preferences and put the patient in control”
Recent work funded by Commonwealth –including work by NCQA and others in refining the definition and creating measures (ACES, CG-CAHPS, supplement to CG CAHPS)

19. Perfect Confluence? Primary Care Medical Home Wagner CCM Comprehensive
First Contact
Coordinated
Continuous
Self-Mtg Support
Decision Support
Medical Home
Information Systems
Delivery system design
This shows the multiple instruments that are being built from the PSAS- (RWJ systems project)- the PSAS is a paper survey research tool, the Physician Office Link is a web based version that has been developed specifically for the GE Bridges to Excellence Project (pay for performance) and the Practice Systems is a web based version that in in development for use in a NCQA recognition program and LEAP IV is the proposed fourth leap for the Leapfrog Purchaser group.
Community Linkages
Wagner CCM
What’s Included? (Infrastructure)
How Much Used? (Extent)
What Functions? (Implementation)
Evidence 19

20. First contact-comprehensive-continuous-coordinated
Theoretical Frameworks Informing Development of PPC_PCMH Based on best available empiric evidence in each area and on testing of reliability and validity of elements in field tests using on site audit as “gold” standard
Chronic Care
Model
Patient Centered
Care
Cultural
Competence
Medical Home
Clinical information Systems
Decision Support
Patient Self-Management
Delivery System Redesign
Community Linkages
Health Systems
Respect Patient Values
Accessible
Family-Centered
Continuous
Coordinated
Compassionate
Culturally Appropriate
Emotional Support
Information and Education
Physical Comfort
Quality Improvement
Culturally competent interactions
Language services
Reducing disparities
Personal physician
Physician directed team
Whole person orientation
Care is coordinated and integrated
Quality and safety
Enhanced access
PRIMARY CARE
First contact-comprehensive-continuous-coordinated 20

21. A Critical Missing Ingredient: REIMBURSEMENT THAT SUPPORTS GOOD CARE

22. Fee For Service Reimbursement: The Road to Ruin for Primary Care
Rewards and encourages volume and new procedures-not primary care
Is largely influenced and controlled by CPT-4 coding panels and the Resource Utilization Committee (ie: sub-specialists)
Makes first contact, continuous, coordinated and comprehensive care an economic hardship for most practices
Treadmill-have to see 20 patients a day to pay for staff-and 10 more for clinicians to make a reasonable living

23. Conclusion: Too Little Wrong Incentives

24. Linkage of PCMH to Reimbursement: Balanced (and increased) Payment
Pay for Performance
Quality, Resource Use and Patient Experience
Fee Schedule for Visits/Procedures
Payment per Patient for Qualified Medical Homes
(services not normally reimbursed)

25. Goals for PCMH Implementation
Improved quality for preventive services and care of persons with chronic illness
Moderation-or at least, more rational use of resources (lower ambulatory sensitive hospitalization, reordered labs etc)
Improved patient centeredness as expressed in patient experience of care surveys
Enhanced reimbursement for primary care
Improved clinician and staff satisfaction with primary care practice

26. How do we “know” a PCMH when we see one?

27. Need for a Standardized Tool for QUALIFICATION as PCMH
If payers are going to provide extra reimbursement to PCMHs, they need an valid and reliable, actionable tool
When reimbursement at stake, major problems with
Use of practice (clinician) surveys without documentation or on site verification
Use of clinical performance measures or patient experience of care (sample size, cost, risk adjustment)
Critical for practices to have standardization since practices may participate in projects for multiple payers

28. PPC-PCMH Development
Existing PPC 2006 (based on PCM) modified with input from AAFP, AAP, ACP and AOA
Align standards with Joint Principles of PCMH created by four groups
Incorporate critical attributes of PCMH not in CCM
Define foundational elements (“must pass” requirements)
Endorsed by NQF

29. Research Findings: Validity of Self-Report
Practices can report on systems, however…
Overall agreement with an on-site audit ranges from high (clinical information systems, quality improvement) to low (care management, population management)
Several factors may explain lack of agreement
Variable implementation of systems across sites and conditions
Variations in staff members’ exposure to systems
Lack of familiarity with systems
Conclusion: Need Audit or Documentation

30. Correlation of Systems, Clinical Performance
Published and in process research on PPC
Presence or absence of EMR per se, correlates ONLY WEAKLY with clinical measures
However, practices with fully functional EMR’s achieve highest scores on PPC
Overall PPC score, and some sub-scores have positive correlation with higher clinical performance on measures tested (diabetes, CV, depression)
Overall PPC score and some sub-scores have positive coorelation with lower inpatient days for ambulatory sensitive conditions
Overall PPC score does NOT appear to correlate with overall patient experiences of care but with selected sub-components (ACES- questions with variance attributable to practice level)
More research needed on all aspects –especially on relationship to cost and utilization: ER visits; tests; specialty care; drug interactions etc

31. PPC-PCMH Content and Scoring
Standard 1: Access and Communication
Has written standards for patient access and patient communication**
Uses data to show it meets its standards for patient access and communication**
Pts 4 5 9
Standard 2: Patient Tracking and Registry Functions
Uses data system for basic patient information (mostly non-clinical data)
Has clinical data system with clinical data in searchable data fields
Uses the clinical data system
Uses paper or electronic-based charting tools to organize clinical information**
Uses data to identify important diagnoses and conditions in practice**
Generates lists of patients and reminds patients and clinicians of services needed (population management) 2 3 6 21
Standard 3: Care Management
Adopts and implements evidence-based guidelines for three conditions **
Generates reminders about preventive services for clinicians
Uses non-physician staff to manage patient care
Conducts care management, including care plans, assessing progress, addressing barriers
Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities 20
Standard 4: Patient Self-Management Support
Assesses language preference and other communication barriers
Actively supports patient self-management**
Standard 5: Electronic Prescribing
Uses electronic system to write prescriptions
Has electronic prescription writer with safety checks
Has electronic prescription writer with cost checks
Pts 3 2 8
Standard 6: Test Tracking
Tracks tests and identifies abnormal results systematically**
Uses electronic systems to order and retrieve tests and flag duplicate tests 7 6 13
Standard 7: Referral Tracking
Tracks referrals using paper-based or electronic system** PT 4
Standard 8: Performance Reporting and Improvement
Measures clinical and/or service performance by physician or across the practice**
Survey of patients’ care experience
Reports performance across the practice or by physician **
Sets goals and takes action to improve performance
Produces reports using standardized measures
Transmits reports with standardized measures electronically to external entities 1 15
Standard 9: Advanced Electronic Communications
Availability of Interactive Website
Electronic Patient Identification
Electronic Care Management Support
**Must Pass Elements

32. PCMH Must Pass Elements
PPC1A: Written standards for patient access and patient communication
PPC1B: Use of data to show meeting standards
PPC2D: Use of paper or electronic-based charting tools to organize clinical information
PPC2E: Use of data to identify important diagnoses and conditions in practice
PPC3A: Adoption and implementation of evidence-based guidelines for three conditions
PPC4B: Active support of patient self-management
PPC6A: Tracking system to test and identify abnormal results
PPC7A: Tracking referrals with paper-based or electronic system
PPC8A: Measurement of clinical and/or service performance
PPC8C: Performance reporting by physician or across the practice

33. How PPC-PCMH Recognition Works
Physician/practice
Self-assess, collect data using Web-based software
Submit documentation to NCQA when ready
May be asked to submit more data if needed
NCQA
Evaluates and scores all applications
Checks licensure of physician
Audits a sample of applications
Posts Recognized physicians on web
Distributes list of Recognized physicians monthly to health plans and others
Physicians sent media kit, press releases, letter & certificate
There are some differences between the programs that we’ll touch on but this is a generic overview of the process.

34. Myths
Small practices can’t qualify (>20% of qualified practices are solo physician sites/practices)
Passing (25 points) is too hard (practices do not have to submit tool until they score above passing)
Passing (25 points) is too easy (estimate fewer than 15% of practices could pass without making changes)
You have to have an EMR to pass (can get nearly 50 points without)

35. Implementing and Evaluating PCMH
Educational
Support
Office Systems
Decision Support
Information Technology
Delivery System Design
Patient Support
Individual
Clinician-Staff
Attitudes, behaviors
and proficiencies
Inputs
Patient Centered
Ongoing Care
Output
MOC
(Boards)
Practice Evaluation Programs
NCQA
Qualification
Evaluation
Programs
Tools
Patient
Experience
of Care
Measures
(CG-CAHPS)
Clinical Process
And
Outcome Measures
(Recognition programs
& Group/plan data)
Office
Systems
Assessment
(PPC-PCMH)

36. What Will be Needed for PCMH to Succeed?

37. Education, Education, Education
Education is NOT lectures or traditional CME
Education must be at all levels –student, resident, and practice-and all types of practitioners and support staff

38. Education- Practitioners
Knowledge, Skills, Attitudes-as individuals
Collaborative “team” practice (clinical staff, support staff and other physicians)
Population health-as a link between personal and public health
Quality measurement and improvement basics
Patient self (or better “collaborative) health and care management support

39. Some Promising Models (of many)
New York City
Department of Health providing EHR to 2,000 MDs serving Medicaid population; implementation and QI support
Goal to reach PPC-PCMH Level II within 2 years
Mid-Hudson Valley
150 practices participating in THINC consortium with common EHR, interoperability and implementation support
North Carolina Medicaid
Nurse care managers shared by practices-reported >50 million in savings/year
Geisinger (reported in Health Affairs)
Introduced in Geisinger Health System
Reduced ambulatory care sensitive hospital admissions
CMS Demonstration
Large Scale (>200 practices in each of eight regions)
Practices could potentially earn nearly $100,000/MD/year
Will use nurse case manager model similar to North Carolina

40. Is the PCMH enough?

41. Future Model of Care: Patient Centered Medical Home as Foundational
Hospital
Sub-specialty “Medical Home Neighbor”
Sub-Specialty Procedural Practice
Patient-Centered
Medical Home
Insurer

42. The Future Model of Care: Step III Patient Centered Integrated Delivery System
Patient Centered Hospital
Sub-specialty “Medical Home Neighbors” Referrals and Procedures
Patient Centered Medical Home
Data Center
Insurer

43. Summary: Issues to Consider
PCMH is not THE answer to our cost and quality problems, but a vital building block
Challenge to provide sufficient help to practices to become PCMH’s to enable them to achieve and demonstrate the cost savings and quality improvement we need
Challenge to build on the PCMH to create virtual accountable entities (for primary, specialty care and hospital care)