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HOME SWEET MEDICAL HOME

Brian T. Engel, MDPediatrician, Northpointe PediatricsChairman, St John Medical Group PGIP

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Introduction

Patient-Centered Medical Home (PCMH) Defined

PCMH-The Past PCMH-The Present and The Future PCMH Success Northpointe Pediatrics PCMH Challenges Summary

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American Academy of Pediatrics (AAP), 1967

A medical home is primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective

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Home Sweet Medical Home, 2009

Your medical home at Northpointe Pediatrics is a place that can take care of all your children’s health care needs from “cradle to college”. However, it is more than a place; it is a continuous relationship with your child’s pediatrician and our team of medical professionals that puts the patient at the center of care.

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PCMH-The Past

Pre-1980: Fee-For-Service Model– High costs, trust of physicians and “the system” is high

(blind faith?)

1980’s and 1990’s: Managed Care Model and Gatekeepers– Lower costs, but distrust of physicians and “the system”

soars (rationing care?)

Early 2000’s: Hybrid Model (Modified FFS/Managed Care)– Costs escalating, distrust rampant (Gatekeeper is dying

breed)

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PCMH-The Present and The Future

“Back to the future”– Re-birth of the PCMH (Designations by NCQA

2008 and BCBSM 2009)• Out with the bad:

– The Gatekeeper is dead and buried

• In with the good: – Re-establishing respect and trust between patients,

physicians and payers– Primary care physicians (PCPs) are patient advocates

that can help the patient and their families navigate the heath care system

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PCMH Success

We all must change our way of thinking…– Wheezing ≠ Allergist or ER visit– Zits ≠ Dermatologist visit– Sprained ankle ≠ Orthopedic or ER visit– Obesity ≠ Gastric Bypass

Success depends on the mutual respect, trust and cooperation between the patient, the PCP (and his/her team), the specialists and the payers

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Northpointe Pediatrics PCMH

Childhood Obesity – The problem:

• 75% of health care dollars ($1.5 trillion) are spent on chronic conditions

• In 1998 $74 billion was spent on obesity-related conditions and in 2008 $147 billion was spent

• 33-35% of kids are overweight (BMI>85%), 17-20% of kids are obese (BMI>95%)

– Our solution:• Chronic Care Travel Team (with Medical Network One) was

established in 2006 with a focus on Individual Care Management

• The CCTT is a physician-lead team which includes an RN, Dietician, Exercise Specialist and a Wellness Counselor

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Northpointe Pediatrics PCMH

Asthma Registry– The problem:

• PCPs (like us) were doing a good job, but not a great job, of managing chronic conditions like asthma

– Our solution:• An Asthma Registry: an electronic database to

monitor and manage ALL our asthmatic patients which is available at the point-of-care; the registry incorporates evidence-based guidelines

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Northpointe Pediatrics PCMH

Physician Dispensing – The problem:

• Our patients would at times leave our office and either be non-compliant (they didn’t fill the medication prescribed) or experience medication errors

– Our solution:• In 2006 we started dispensing medications at the

point-of-care in a our office; since then, we have seen improved patient compliance, reduced medication errors, lower costs for the patient and the payers (our GUR is 87%) and improved patient satisfaction

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Northpointe Pediatrics PCMH

Patient Portal– The problem:

• Poor communication between physicians and their patients• Patients need a secure, confidential and portable Patient

Health Record (PHR)

– Our solution: • Our Patient Portal, RelayHealth, allows online

communication between our office and our patients• Patients and their family members have free access to a

PHR• Patients can request online prescription refills and

renewals, specialist referrals, appointments, and web visits

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Northpointe Pediatrics PCMH

Performance Reporting– The problem:

• Insurers data about key chronic conditions and preventative care showed “gaps in care”; most of the “gaps” were opportunities to improve care, some of the “gaps” were from poor data collection

– Our solution:• Our registries for chronic conditions (like asthma) and

preventative care (MCIR, BCN’s Health-e Blue, HAP’s Member Health Manager) help us implement care delivery systems that outreach to patients and close “gaps in care”

• The outcome: Patients benefit (care is better and proactive rather than reactive), physicians benefit (P4P dollars and better work flows for improved patient care), payers benefit (healthier patients and lower costs)

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Challenges

Childhood Obesity– Obesity is still not a billable code– BCBSM/BCN are the only insurers that recognize the

CCTT with payments (T-codes) Asthma Registry

– Some patients are suspicious of “specialist” care by their PCP

– Some specialists feel threatened by a loss of business, but shouldn’t be

Physician Dispensing– Although physician dispensers are contracted

participants of the Good Neighbor Pharmacy Provider Network (GNPPN), the entity is still not universally recognized by insurers

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Challenges

Patient Portal– Even though we deal with the “techie” generation,

only 20% of our 12,000 patients communicate with us online

– Are Obama’s “meaningful use” stimulus dollars for EMR attainable?

Performance Reporting– An inherent conflict exists: while physicians are

promoting the PCMH concept, some insurers are still “rewarding” patient care outside the PCMH (no ER co-pays, Urgent Care check-ups, Minute Clinic visits)

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Summary

The PCMH is the answer to our health care woes in primary care

We can achieve quality patient-centered medical care in a cost-effective fashion

To do so, we must go “back to the future” and re-establish a trusting and cooperative relationship between patients, physicians and payers

Change is hard, but change is good!