IBM Patient-Centered Medical Home Pre Launch Briefing

© Copyright IBM Corporation 2009

Patient-Centered Medical Home

What, Why and How?

Pre-Launch Briefing

May 27, 2009

Patient-Centered Medical Home: What, why and how? | Briefing | Apr 11, 2023 2 © Copyright IBM Corporation 2009

Today’s speakers

F. Daniel Duffy, MD, MACPSenior Associate Dean for Academics,University of Oklahoma School of Community Medicine

Martin S. Kohn, MD, MS, FACEP, CPESenior Managing Consultant, IBM Healthcare Strategy and Change Practice

Edgar L. Mounib, MBA, MPHGlobal Healthcare Lead, IBM Institute for Business Value

Beginning May 28th, download study atwww.ibm.com/healthcare/medicalhome


Abstract

The patient-centered medical home (PCMH) can serve as a foundation for transformation of the U.S. healthcare system – if appropriately conceived and properly implemented. But it can also suffer from unfettered expectations. This study makes the realistic case for why and how stakeholders can participate in PCMH initiatives, identifies critical issues and makes recommendations for best practices to increase the likelihood of initial success and sustainability.

Preface


Agenda

Introduction

The medical home: What is it? What isn’t it?

Why should it be done now?

How should it be done?

Conclusion

Agenda


Despite having many fine care delivery organizations and caregivers, the U.S. healthcare system is badly broken

High, rapidly rising costs

US$2.5 trillion (17.6% of GDP) will be spent in 2009-US$4.0 trillion (almost 20% of GDP) will be spent in 2015

Highest per capita spend among OECD countries in 2006-48% more than Norway, which spends the third-most-2.4x the OECD average per capita spend

No link between higher costs and quality or safety

98,000 to 195,000 people killed per year by medical mistakes57,000+ dying from inadequate care2 million hospital-acquired infections with 90,000 dying per year4-fold variation in costs with similar qualityRanked 37th in overall health system performance by WHO22nd in life expectancy, 28th in infant mortality and 30th in obesity among the 30 OECD countries

Access issues45+ million uninsured15+ million under-insured, most who are working

Introduction

“Let there be no doubt ... Healthcare reform cannot wait, it must not wait, and it will not wait another year.”- U.S. President Barack Obama, 24 Feb 2009

Source: IBM Healthcare and Life Sciences, IBM Institute for Business Value


Foundational to healthcare transformation is a primary care system that provides comprehensive and timely care

Primary care offers demonstrable benefits that leads to – - Better health outcomes1

- Lower costs1

- Greater equity in health1

For example, Patients who have a regular primary care provider (PCP) – - Incur about ⅓ less healthcare expenditure2

- Have 19% lower mortality2

- Are 7% more likely to stop smoking3

- Are 12% less likely to be obese3

Majority of patients prefer initial care from a PCP, rather than a specialist

Introduction

Source: 1) B Starfield, Milbank Quarterly, 2003; B Starfield, “The best care is primary care” presented at WONCA 2004; The Future of Family Medicine Study; 2) Franks, Peter and Kevin Fiscella. “Primary Care Physicians and Specialists as Personal Physicians: Health Care Expenditures and Mortality Experience.” Journal of Family Practice. August 1998; 3) Arora, Vineet, Sandeep Gangireddy, Amit Mehrotra, Ranjan Ginde, Megan Tormey, et al. “Ability of hospitalized patients to identify their in-hospital physicians.” Archives ofInternal Medicine. January 26, 2009.


From 1998-2008, 57% fewer

medical school graduates entered family practice residencies3

In 2004, the median income for primary care physicians was about

½ that of specialists2

Exacerbating this is a primary care system – the foundation to any healthcare system – that is also broken

PCP shortage is worsening: 35K-44K by 2025- Failure to attract new residents1

- Reimbursement is relatively low and based on quantity2

- Growing levels of frustration

Current primary care practice is geared to treating acute, episodic interventions- Emphasis on triage, not on coordinating care - Minimal communication between providers- Minimal focus on education and self-management - Slow to adopt evidence-based medicine

No tools and support in place such as EMRs Even with tools, evidenced based medicine is more difficult

for PCPs than for specialists because facing more comorbidities or in preventive mode

- Generally lower level of support structure (EMR, support staff, etc.)

Challenge Highlights

Introduction

Source: 1) P.A. Pugno et al., "Results of the 2006 National Resident Matching Program: Family Medicine," Family Medicine 38, no. 9 (2006): 637–646; and T. Bodenheimer, "Primary Care—Will It Survive?" New England Journal of Medicine 355, no. 9 (2006): 861–864; 2) T. Bodenheimer, R.A. Berenson, and P. Rudolf, "The Primary Care–Specialty Income Gap: Why It Matters," Annals of Internal Medicine 146, no. 4 (2007): 301–306; 3) American Academy of Family Physicians. "2008 National Resident Matching Program."


Agenda

Introduction




Conclusion

Agenda


Patient-centric/Personal PCP PCP-directed medical “team” Whole person orientation Care is coordinated and/or integrated Emphasis on quality and safety Enhanced access Appropriate reimbursement

Patient-Centered Medical Home (PCMH) is an approach to deliver comprehensive care, coordinated by a PCP-led extended care team

Brief history of the evolution of the PCMH- 1967: American Academy of Pediatrics defined medical home

concepts related to children with special needs- 2000-present: AAFP and ACP developed and extended the

concept to include care for all patients with chronic illness and patient centeredness

- 2006-07: AAFP, AAP, ACP and AOA develop a common definition of “patient-centered medical home” and link PCMH to reform of payment for physicians

Principles of PCMH

Technology, Services & Applications to Support the

New Collaborative Care Model

Technology, Services & Applications to Support the

New Collaborative Care Model++Personal Relationship with a

PCP and Care TeamPersonal Relationship with a

PCP and Care Team

Proactive Focus on Health, Care Intervention and Chronic

Disease Management

Proactive Focus on Health, Care Intervention and Chronic

Disease Management

“The Patient-Centered Medical Home (PCMH) provides care that is “accessible, continuous, comprehensive and coordinated and delivered in the context of family and community.”1

Source: 1) www.medicalhomeinfo.org/join%20statementpdf



Today’s CareToday’s Care Medical Home CareMedical Home Care

Our patients are those who are registered in our medical home

Care is determined by today’s problem and time available today

Care is determined by a proactive plan to meet health needs, with or without visits

Care varies by scheduled time and memory or skill of the doctor

Care is standardized according to evidence-based guidelines

Patients are responsible for coordinating their own care

A prepared team of professionals coordinates all patients’ care

I know I deliver high quality care because I’m well trained

We measure our quality and make rapid changes to improve it

It’s up to the patient to tell us what happened to them

We track tests and consultations, and follow-up after ED and hospital

Clinic operations center on meeting the doctor’s needs

An interdisciplinary team works at the top of our licenses to serve patients

My patients are those who make appointments to see me

The PCMH concept advocates enhanced access to comprehensive, coordinated, evidence-based, interdisciplinary care

Source: Adapted with permission from F. Daniel Duffy, MD, MACP, Senior Associate Dean for Academics, University of Oklahoma School of Community Medicine



While other approaches have addressed some PCMH Principles, none have addressed them all

Factor/Principle PCMH Non-integrated

managed carePay for

performanceDisease

managementChronic care

model

Purpose/focusFacilitate partnership between PCP and patient

Ideally: cost, quality; Actually: control utilization

Meet operational goals with financial incentives

Meet specific management targets for chronic disease

Org. framework for chronic care mgt and practice improvement

Patient centric/ personal physician

Yes No NoMaybe, often led by actors independent of primary care

Yes, for chronic illness

Physician directed medical “team”

Yes No No No Yes

Whole person orientation

Yes No No No Yes

Care is coordinated and/or integrated

YesNo incentive for coordination

No incentive for coordination

MaybeYes

Emphasis on quality and safety

Yes, evidence-based and best practice; improved outcomes rewarded

No, reduced utilization rewarded

Indirectly; process targets rather than outcome ones

Yes, particularly for diseases

Yes, for chronic illnesses

Enhanced access Yes No, reduced access No Maybe No

Appropriate reimbursement

Yes for PCPs, unclear for others

Potential conflict in motivation

No, still volume driven

Partially, if evidence-base used

No


Aligned Mixed alignment Not alignedAlignment with PCMH Principle:



Nevertheless, the PCMH model needs additional support

Better clinical content- Evidence-based or personalized health and care/ability to incorporate into practice- Tools to help with correct and complete diagnosis

Changes with and support from other stakeholders since the PCMH model cannot be dropped into the current system for optimal results; examples include:- Consumer responsibility/changing consumer behaviors- Reimbursement changes/payment system reform- Alignment, coordination or integration with care delivered by others outside the medical home (e.g. specialists) in other care settings (e.g. ambulatory surgery centers or hospitals); this has been called the “medical neighborhood.”

- Policy reform to allow payers to collaborate in designing incentive systems- Universal coverage/coverage decisions

Infrastructure to support PCMH model (IT and other services) targeting the consumer/patient and the clinicians (see next slide)




For example, Health Plans or other entities could offer a variety of services or tools both to members and to providers

Providers• Tools and resources for virtual interdisciplinary care delivery teams

• Tools to support better access to clinical and patient information

• Tools to support cost/quality transparency

• Tools or services to provide coordinated, integrated care

• Tools to enhance access (e-visits, telemedicine)

• Tools to streamline administrative processes

Individuals• Health/wealth planning and management

• Risk assessment• Personal Health Records• Connected personal medical devices

• Trusted clinical information

• Collaboration tools and trusted sites

• Benefits selection• Provider selection

Examples of Tools and Services

• Health coaching • Value coaching




Agenda

Introduction




Conclusion

Agenda


Great majority of patients prefer to seek initial care from PCPs rather than specialists, but their unhappiness with their PCP experience is growing.

50% of patients leave office

visits not understanding what the physician told them

Why PCMH should be done now? The current system does not work and key to its reform is primary care

Increasing unsustainability of healthcare system – mounting cost, quality and access issues- Impacting economic viability of industries, governments- Impacting resources for other investments needed for sustainable economic growth

- Studies estimate that if every American had access to PCMH, national healthcare expenditures would drop 5.6%, or a savings of at least $67B per year

Increasing focus on wellness/prevention – pillars of primary care- For example, $1B in the “American Recovery and Reinvestment Act”

Can be done now without robust IT infrastructure but not scalable

Challenge Highlights




Patient Outcomes/Loyalty Patient Satisfaction/Activation Physician Leadership/Ownership Chronic Disease Management Patient Centered Focus Patient Compliance Employee Productivity

PCMH helps address systemic cost, quality, and access issues

Costs ED Visits PMPY Redundant Tests Unnecessary treatment Hospital stays and readmits PMPY Overall mortality

Potential impacts of PCMH




Why it can be done now? There is a growing evidence that PCMH can work

Others have done it and demonstrated success- Various focused, regional approaches have worked (next slide)

Technology/IT can support and enable- Integrate and synthesize data from multiple sources into actionable information

- Ability to disseminate data and standards- Guidelines/best practice work flows/ coordination

- Clinicians and patients are using technology today

Momentum and public awareness of need for change- Increasing awareness that change is inevitable- Dichotomy between cost and outcomes


If the U.S. is serious about closing the quality chasm, it will need a strong primary care system, which requires fundamentally reforming provider payment, encouraging all patients to enroll in a patient-centered medical home, and supporting physician practices that serve as medical homes with the information technology and technical assistance for redesigning care processes.

- Karen Davis, President, Commonwealth Fund



RI

To date, more than 30 PCMH pilots have been initiated and many are demonstrating cost, quality and access improvements

Multi-Payer pilot discussions/activity

Identified pilot activity

No identified pilot activity

“Voice of Detroit Initiative” – 25K uninsured•Reduced ED use by over 60%. •Reduced costs from uncompensated care by 42%•Among homeless and substance abuse patients, reduced hospitalizations by 55% and reduced cost of care by 24%

Community Care of NC (CCNC) – 785K Medicaid enrollees• Asthma: 34% lower hospital admission rate; 8% lower ED rate;

average episode cost for enrolled children was 24% lower; 93% received appropriate inhaled steroid

• Diabetes: 15% increase in quality measures• Program savings: 13% lower ED rate; ~$150M in last fiscal year

BCBS of North Dakota - Diabetes care management• Reduced hospital admissions by 6%, reduced ED visits by 24%• Improved patient satisfaction with care, • Program savings of $1213 per patient ($233,000 total) (2006)

Geisinger Health System – Integrated delivery network in Western Pennsylvania

• Reduced hospital admissions by 20%• Reported medical cost savings of 7%


Horizon BCBS New Jersey•7300 diabetics

•Improved compliance•Reduced costs 10%

BCBS Michigan – new •1,000 physicians•Increased payments•2 million patients•$30 million in incentives

Source: Patient Centered Primary Care Collaborative (http://pcpcc.net/), IBM Healthcare and Life Sciences, IBM Institute for Business Value


PCMH is also drawing support from key stakeholder groups and is being bolstered by lawmakers

PROVIDERS•Primary care associations (333,000 physicians)•Associations representing integrated delivery networks, academic medical centers, community hospitals (4,000)

PURCHASERS•Most Fortune 500 (100M lives)•Federal, State Governments

Medicare: Demonstrations from H.R. 6111 – “Tax Relief and Health Care Act”; more Medicare implementations

Medicaid: NC, MO, LA already planning and implementing; Transformation Grants

S-CHIP: Language to encourage transition to medical home model

Health IT Legislation and SGR Reform: Medical home language, encouragement for PCPs to adopt support systems

Quality Improvement Organization 9th Scope of Work Language

Medicaid Transformation Grants

Legislation Highlights

SUPPLIERS•Pharmaceutical and medical device companies •Solution providers

HEALTH PLANS•Health plans including Aetna, BC/BS, Cigna, Humana, MVP Health Care and United Healthcare

CONSUMER ADVOCATES•Unions•Special interest groups

Supporters of the Patient Centered Primary Care Collaborative


Source: Patient Centered Primary Care Collaborative (http://pcpcc.net/), IBM Healthcare and Life Sciences, IBM Institute for Business Value


There are demonstrable benefits to the Patient, as well as to caregivers who work at the “top of license” in an integrated team

Patient- Help from a trusted resource to navigate healthcare system- Empowered to make better-informed healthcare decisions- Receive safe, effective care with compassion- Achieve healthier outcomes collaboratively with extended

care delivery team- Improved relationship with PCP, health plan

Primary care provider- Redefine patient relationship to deliver more

comprehensive, coordinated care- Fair compensation for PCMH services, as well as rewards

for improved clinical outcomes- Through a shift in incentives, able to more effectively

provide wellness and preventative care- Better supported to deliver quality care to patients

Nurse- Develop better relationship with patients- More involvement with patient care and support (for

example, patient education, behavioral change, preventive care, proactive care planning)

Pharmacist- Participate fully in team-based care (for example, help

determine medication and reasonable formularies)

Social worker- More integrated role to address key patient needs (for

example, Medicaid)

Hospital- Serve PCMH patients whose conditions may not be as

severe as non-PCMH patients- Potentially reduce admissions from patients who cannot

pay- Potentially reduce number of re-admissions, for which

there may no or reduced payment.

Specialist- Receive higher quality referrals, with more complete

documentation- Improved focus on area of expertise without having to

assume management of patient’s primary care- Opportunity to offset income losses by participating in

financial incentives for coordination and quality (for example, telephone consultations).

Potential benefits by stakeholder




PCMH also offers potential benefits to Payers, the Life Sciences, and Governments

Health plan- Improved member and employer satisfaction- Expend healthcare resources with less waste and

greater effectiveness though coordinated evidence-based care.

Employer- Purchase healthcare based on value and

potentially see medical cost savings- Maintaining more present and productive

workforce, in part, through improved wellness and prevention.

Pharmaceutical and other life sciences- Improved appropriateness of and compliance with

therapeutics- Enhanced pharmacovigilance of products, post

clinical trials.

Government- Potential to improve care quality, reduce wasteful

healthcare expenditures- Address frustration with the current uncoordinated

and impersonal system.

Communities and society- Potential for a healthier, more productive citizenry- Potential to allocate dollars so that they have

greater return.

Potential benefits by stakeholder (continued)




Agenda

Introduction




Conclusion

Agenda


When correctly implementing a PCMH pilot, key steps must be taken to help ensure consistent alignment with the problem at hand

What is the problemWhat is the Problem?

• What cost/quality/ access issue(s) are you targeting?

• Near, long term?• What are your vision, guiding principles?

What are CommonImplementation

Issues?

• Incentives to participate

• Members/patients• Initial funding• Governance• Key metrics• Reimbursement• Physician practice transformation

• Technology infrastructure

• Patient attribution• Sustainability

What is the problemWhat are the Best Practices?

• Who else has addressed our problem?

• What can we learn from them to address our key implementation issues?

Is Our ApproachConsistently Aligned

With Problem We are Trying

to Solve?

•Do you have…• An appropriate

governance structure with the right participants?

• An agreed-upon project plan and strong project manager?

• Capabilities to support the patient cohort?

• Metrics to measure alignment with and progress toward original objectives?




Registration, MH assignment, billing, contracting, compliance with contract

Access to appointments, non-visit advice and help

Clinical Preventive services

Acute Care, ER and UCC Management

Patient Activation & Behavior Change

Social & Mental Health Services

Medication Monitoring

Diagnosis and Drug Management

Specialists

High-risk Care Management

0% 25% 50% 75% 100%

Medical Home Multidisciplinary Team

Clerical

Nursing

Physician, PA, NP

Social Work

Pharmacy & Nursing

Volume of services

All team members collaboratively contribute at the “top of their licenses,” helping the overall practice operate more efficiently and effectively

Source: Adapted with permission by IBM from F. Daniel Duffy, MD, MACP, Senior Associate Dean for Academics, University of Oklahoma School of Community Medicine


Sample medical home PCP practice

Sample Implementation Issue


Key Metrics – Measurement and evaluation processes are critical because of their effects on incentives, resulting organizational learning and other factors

To date, medical home efforts have used a combination of the following types of key metrics:- Costs: Impacted by things like the types and number of patients, as well as duration of initiative- Process of care: Include appropriate screening for traditional conditions, alignment with NCQA

accreditation measures or targeted conditions that are endemic to local population- Outcomes of care: Measures change in health for a patient or a cohort, such as individual

conditions and patient compliance (e.g., tracking HbA1c) or utilization (e.g., ER visits)- Service: Have focused on operational aspects, such as the wait until the next appointment- Patient and caregiver satisfaction: Demonstrates the PCMH initiative’s commitment to quality

and in improvements by assessing the satisfaction of patients and clinicians- Coordination of care: Are more innovative but require a sophisticated tracking system

University of Oklahoma is developing a set of measures that accounts for the rapidity of referrals and getting the referral and includes quality and process measures

Sample assessment questions for include the following:- Is there an agreed-upon set of metrics that are aligned with your original problem?

Pilot phase? Full roll out?Regular updates?

- Is the data needed easy to collect, analyze, report, and act upon?



Sample Implementation Issue


Agenda

Introduction




Conclusion

Agenda


There is no reason to wait to invest in the medical home but invest wisely

The medical home is not a “silver bullet” but can become a cornerstone for revamping primary care – an essential component of the overall transformation of U.S. healthcare

To support medical homes, we need better clinical evidence, changes in responsibilities of key stakeholders, and a cross-organizational infrastructure to support coordinated care

It will not be easy to implement medical homes on a large scale even with the current momentum behind them, given challenges such as funding and the level of change required

Fortunately, best practices are emerging for common issues related to planning and implementation - When appropriately applied, they can help increase the likelihood of success for an initial

rollout and for a sustainable model


Conclusion


For more information, please contact

AuthorsJim Adams, MBA

Executive Director, IBM Center for Healthcare ManagementE-mail: [email protected]

Paul Grundy, MD, MPH, FACOEM, FACPMGlobal Director of Healthcare Transformation, IBM

E-mail: [email protected]

Martin S. Kohn, MD, MS, FACEP, CPESenior Managing Consultant,

IBM Healthcare Strategy and Change practiceE-mail: [email protected]

Edgar L. Mounib, MBA, MPHGlobal Healthcare Lead, IBM Institute for Business Value


Guest SpeakerF. Daniel Duffy, MD, MACP

Senior Associate Dean for Academics,University of Oklahoma School of Community Medicine


Beginning May 28th, download study atwww.ibm.com/healthcare/medicalhome


Thank you!

IBM Patient-Centered Medical Home Pre Launch Briefing

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Transcript of IBM Patient-Centered Medical Home Pre Launch Briefing