Effective Management of Health Care Costs

The Patient Centered Medical Home: Re-Organizing Primary Care Delivery and Reimbursement to Improve Quality, Cost and Access 

Kenneth J. Phenow, MD, MPH

Senior Medical Executive, CIGNA Healthcare of Texas and Oklahoma

Systems are perfectly designed and operated to produce the results they get. (Don Berwick)

Traditional fee-for-service payment rewards piecemeal work and volume of services rather than prevention of illness and coordination of care (Reactive vs. Proactive / Disease vs. Health)

The more procedures a physician performs and the higher the value of the procedure, the more the physician is paid

(Rewards specialization and more care, not coordination of care). Primary Care currently operates in a transaction-based, episodic

and volume-based reimbursement model that does not recognize the value of comprehensive, coordinated high value care

(Fragmented vs. Organized / Episodic vs. Coordinated Care)

Imagine if Health Care Delivery was……..Imagine if Health Care Delivery was……..

Simple / CoordinatedOngoing and ContinuousPrimary Care basedQuality & Cost ConsistencyPatient CentricProactivePreventiveEfficientOutcome drivenAffordableHigh Quality & Value

Changes to the delivery system Incent quality not quantity of medical care

No cost sharing for preventive care

Better coordinate care for patients with chronic diseases

Ensure patients receive clinically recommended treatments and follow-up

Reduce duplicative testing and re-hospitalization

Integrate with community health resources to provide more holistic patient care

Expand coverage and access

Medical Homes are a Key Component of Each of the Current Reform Proposals– Senate HELP Committee, – Senate Finance Committee, – House Tri-Committee

Primary care has a critical role to play in reform

Health reform will facilitate adoption of advanced primary care or medical home models

Health Reform Will Improve The Way Care Is Delivered For All Americans

Our Primary Care System Must Be Transformed To Meet Future Demands From Chronic Disease and Reform

Current challenges

Emergency room visits increased by 36% between 1996 and 2006; 47% of ED visits could have occurred in a physician’s office

20% of patients are readmitted within 30 days of hospitalization, most of which are avoidable

50% of patients that are readmitted do not see a physician after their first hospitalization

75% of health care spending is for patients with chronic diseases Over two years, the typical Medicare patient sees 2 different primary care

doctors and 5 different specialists Millions of additional Americans will enter the primary care system with health

reform

Advanced primary care models, like medical homes, can provide the coordination mechanisms and decision support to improve quality, cost, and satisfaction

– http://blogs.wsj.com/health/2008/08/06/emergency-room-visits-hit-record-high/– http://www.medicalnewstoday.com/articles/157206.php– http://www.boston.com/news/local/massachusetts/articles/2009/04/24/er_visits_costs_in_mass_clim

Patient Centered Medical Home Concepts

Principles Personal Physician Physician directed

practice Whole-Person orientation Coordinated care Quality and safety Enhanced access Payment for value

NCQA Standards Access and communication Patient tracking and registry Case management Patient self-management

support Electronic prescribing Test tracking Performance reporting Advanced electronic

communication

Potential Delivery System Improvements via PCMH

Seen as a solution to “care fragmentation” as a driver of increasing health care costs

Seen as a facilitator of primary care recognition and re-emergence Seen as a driver of improved quality, affordability and high value

patient-centric health care Enhanced coordinated health care experience Improved patient safety and reduced duplication of services Care continuity & improved care transitions Improved practice profitability and physician satisfaction Improved quality and effectiveness of care along with patient

satisfaction Reduced utilization of supply-sensitive care from value-based

payments

PCP Health Advocate

• Patient centric• Personal care • Holistic coordinated

Practice Resources CIGNA Solutions

Coordinated Care & Disease Registry

Information

Evidence based guidelines

E-Prescribing

Electronic Medical Record

Inpatient Care Transition

Inpatient/ER Follow-up

Lab Test & Referral Results Follow-up

Clinical Programs•Disease Management

•Case Management

•Health Information Line

•HRA, On-line coaching

Patient Specific •Re-admission Predictor•Risk Predictor•Gaps in Care

Management Reports•Population Based•Episode Based•Focused Trends

Access

Comprehensive, Accountable, Collaborative Care

Improved QualityIncreased Satisfaction

Lower Costs

Supply Sensitive Care - Generics - Value Referrals

Key Focus Areas

Value Referrals

Value Pharmacy

Access

Informatics Enabled

Embedded Care Coordination

Evidence Based Care

Value Pharmacy

Acute Chronic Preventive

Engaging Patients

Informing Empowering

Medical Clinic of North Texas (MCNT) and CIGNA PilotWhy MCNT as a PCMH Pilot? 120 PCP’s in 42 practices across North

Texas region Enabled in all locations with fully

interoperable EMR Provide services to about 12,000 CIGNA

patients Clinically Integrated with over 20 Clinical

Protocols around Chronic Disease In 2008 CIGNA Care Designation (CCD)

Data ranked MCNT as #2 in market for Quality and Top 1/3 for Efficiency

MCNT’s mission of keeping the healthy healthy is congruent with CIGNA's mission of improving health, well being and security for its participants

MCNT is eager to transform their practice guided by foundational elements of the NCQA PCMH standards

Tools/ Data to Empower MCNT Care Coordinator funding & support CIGNA Gaps in Care information High Acuity Patients (HAP) data:

including ER visits, admissions, high tech radiology, specialist referrals, pharmacy and Predictive Model results to help drive improved care coordination efforts

Value based referral data for CIGNA Designated specialists, preferred ancillaries and Center’s of Excellence facilities & procedures

Pharmacy data on overall generic and non brand prescription utilization

Bi-annual Report Card on key utilization and quality data

MCNT and the PCMH CIGNA Pilot

Expected Clinical results from MCNT PCMH pilot Enhanced coordination of care Timely access (after hours and weekends) for Acute needs Management of Chronic Disease Use of Preventive services Value based referrals Utilization of preferred ancillary service vendors Generic and preferred brand drug utilization Closure of gaps delineated in Gaps in Care (2-way electronic data

transfer) Clinical Collaboration between CIGNA and MCNT

Bottom Line: Improved Quality and Cost of Care with Increased Patient & Physician Satisfaction

Medical Home Reward Model

TMCTREND vs.

Market

TMC Trend

Must pass elements compared to market.

• Quality: EBM1 Improved or maintained at better than market average

• Affordability: TMC2 Trend better than market 3 average

Employer 2X

Advanced Care

Management Payments

Bonus Pool

X% Y% Z%

Medical Group

Affordability

Medical Group

Quality4

Employer

Size of X & Y is dependant on group’s initial evaluation and other contractual changes.

Maximum Payment Group capped at 3% of TMC1EBM – Evidence Based Measures of Quality2TMC – Total Medical Cost – age, sex and case mixed adjusted3Market – Mutually agreed upon market comparisons4Quality – Portion of potential quality bonus depends on degree of improvement in EBM and patient satisfaction (when available)

YES

CIGNA Medical Home Experience (est. 2008)

Patient Centered Primary Care Collaborative (PCPCC): Founding Plan member

Comprehensive, Accountable, Collaborative Care PCMH Pilots To Date– Dartmouth-Hitchcock launched 6/08: CIGNA’s first plan sponsored pilot

– Medical Clinic of North Texas: rolled out 9/1/09

– ProHealth of Connecticut: rolling out 1/1/10

– Employer driven: Two in Maine, one in TN, VA planned for 2010

– Network driven: St. Louis (Mercy) planned 2010

– CIGNA Medical Group (Phoenix, AZ) planned 2010

Community Multi-Payer Collaboratives– Active: VT, PA, CO, NH

– Target 1/10 implementation: ME

– In Discussion: TX, WA

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Thank You for Your Attention!

Questions??