The Medical HomeMI 404 – Final Presentation

Chris Davis, Marla Kouche & Ty LeeNovember 29, 2010

Our Call to Action…

Inpatient rates expected to decline for most services due to increasing out-patient management- US Market Forecast of Inpatient from 2010-2020 expected to decline 12%- Primary declines in cardiovascular and general surgery

Patients will continue to seek care in the outpatient setting more often- 17% overall expected growth rate from 2010-2020- Outpatient services are also expected to grow by 30%- Primary increases expected in cancer and general surgery

This “share shift” is the result of- Changing clinical care- Economics around Medicare and government policy

The Key To Our Growth Lies in Strengthening our MD Relationships and System of Care Channels

Source: John Peabody, SG2 Healthcare Consultants: How Will the Reform Decade Play Out?PAGE 2

The Patient Centered Medical Home

Define Patient Centered Medical Home

Successful Medical Home Demonstrations

Define Unmet Patient Need and Business Case

Challenges

Measurement Criteria

Adoption Considerations

Solutions and Recommendations

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The Medical Home Overview

Provision of comprehensive primary care services

Facilitates communication and shared decision making- Patient- Primary Care Provider- Other Care Providers- Patient’s Family

Coordinated care for the patient across the care team

Aimed at more effectively supporting both primary care and chronic disease management

Medical Home Development

American Academy of Family Physicians

American Academy of Pediatrics

American College of Physicians

American Osteopathic Association

Jointly developed the NCQA’s Physician Practice Connections Patient Centered Medial Home Standards

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Joint Principles of the PCMH

Personal physician

Physician directed medical practice

Whole person orientation

Care is coordinated and/or integrated

Quality and safety improvement

Enhanced access

Payment

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Source: Stange, K., Nutting, P. , Miller, W., et al., (2010). Defining and measuring the patient-centered medical home. Journal of General Internal Medicine, 25(6), 601–12

Successful Medical Home Demonstrations

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Source: Fields, D., Leshen, E., Patel, K, (2010). Driving quality gains and cost savings through adoption of medical homes. Health Affairs, 29(5): 819-26.

Insight on the Unmet Patient Need &the Business Model

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The Unmet Patient Need & Business Model

Patient Access to Care- Improved access for patients- Extension of Primary Care with increased volumes increases revenues- Increased patient volumes for health system, utilization of health system services- Utilization of mid-level providers- Further potential for revenues from e-visits and telemedicine

Improved Efficiency of care- Coordinated care- Reduced costs from duplicated procedures- Decreases unnecessary hospitalizations (costs)- Improved patient satisfaction- Health system becomes preferred provider for the area

Achieve NCQA Accreditation- Enhances contracting leverage- Increases reimbursement models FFS + based on level achieved

Efficient

Evidence Based CareImproved Coordination

Decreased Costs

Effective

Decision SupportCare Coordination

Real Time Information

Safe

TimelyMultiple points of

Access

Patient Centered

Improved AccessTeam Care

Lean Design

Equitable

MissionResource conservation

Efficient SystemsAccess

Requirements

Start up cost of approximately $120,000 per physician

Additional Nurse Practitioner/PA

Case Manager to manage 250 – 350 chronically ill patients

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Grants

Section 3502 of the Patient Protection and Affordable Care Act (HHS)- Community health teams eligible for capitated payments

Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration

Federally Qualified Health Centers Advanced Primary Care Practice (FQHCAPC) Demonstration

Additional state and privately funded Programs

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Source: American Hospital Association Committee on Research (September 2010). Patient-Centered Medical Home, AHA Research Synthesis Report. Retrieved from http://www.aha.org/aha/research-and-trends/cor.html.

Risks

Dependent on increase use of Nurse Practitioner / PAs

Ability to fill capacity

Decreased revenue to Hospital due to decreased utilization

No reimbursement for infrastructure

e-Visits and Tele-medicine still in infancy (reimbursement?)

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Medical Home Challenges,Success Measurement Criteria

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Significant Planning Challenges

Our Response

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Significant Execution Challenges

* 65mm Americans live in officially designated primary care shortage areas and only 27% can easily reach their PCP by telephone, obtain after-hours care or advice and schedule timely office visits.

Our Response

Who are our customers?

Customer What They Want Perceived Hurdles Levers

Primary Care Physicians

• Hospital Alignment• Improved Financials• Subsidized IT• P4P Goals• Quality of Care

• Added Burden• Added Responsibilities• Cultural/Collaborative

Workflow Change

• Resource/Incentives• Care Coordinator• Forums• HIT Support (Subsidized

EHR Central Analytics)

Specialty Physicians

• Same as above + referrals • Same as above • Same as above

Care Coordinators

• Organizational support• Improved quality of care

• Change in Existing Model • Paid by health plan

Patients

• Better access, 24 hour• Care coordination• Safety• Improved Outcomes

• Lack of understanding or participation

• Community Awareness Program

Health Plans

• Improved Outcomes• Reduced Cost• Risk Sharing

• Lack of Direct Relationship between initiative and cost

•Central analytics and monitoring

•Risk-based model for incentives

Hospital

• Reduce hospital readmissions• Improve physician

loyalty/referrals• Grow outreach business• Improve the overall health• Chronic disease management• Improve patient safety• Improve quality of care

• Increased Cost & Risk• Cultural change• Reduced Admissions

• Reliance on Grants• Leverage existing investment• Improved volume Admissions (share shift) Outreach• Reduced 30 day

Readmissions

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Pilot Measurement

Efficient- 7% savings in total medical costs (Geisinger Health System)- 1.5:1 Return On Investment (Group Health)

Effective - 6% Fewer Hospitalization (Group Health, North Dakota)- Reduced cost related to specific DRGs (Comm. Care of NC)

- Diabetes & Asthma (Community Care of NC)

Timely - 10% increase in preventative care visits (CCHAP)

Patient Centered - Positive Patient Satisfaction Survey:

Focus on easy access, comprehensive care, coordination of care, personal relationship (TransforMED National Demonstration Project)

– Reduced physician and care-team burn-out (Group Health Seattle)

Equitable- >90% practice coverage across region (Colorado CCHAP)

Safety- 16% ER Visit Reduction (North Carolina Health System)

Contributing Sources for slides 15-18: Health Affairs 29 No 5 (2010): Driving Quality Gains Through Adoption of Medical Homes, Amednews.com: (2010) Medical Homes for Medicaid: The North Carolina Model, Health Affairs, Vol 27: Continuous Innovation In Health Care-The Geisinger Experience & Robert Wood Johnson Foundation, Sept 14, 210 PCMH: How widely adopted?

SECTION A TITLE OPTION 2Medical Home

Adoption Considerations,Benchmark Solutions &

Recommendations

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Medical Home Benefits

Source: Healthcare IT News 9/1/2009 and Fierce Health Finance 5/5/2010 (retrieved from: http://www.healthcareitnews.com/news/study-medical-home-model-increases-quality-care-reduces-cost and http://www.fiercehealthcare.com/story/medical-home-program-leads-significant-cost-savings-fewer-hospitalizations/2010-05-05)

Group Health medical homes & 9,200 patient pilot- Treatment provided by Seattle-based Group Health medical home- Payback: significant savings translated to a $1.50 return for every $1.00 spent

over two-years from 2006 to 2008 - Rollout now being implemented to 26 medical centers across the state of Washington

Results- Email & mobile technology- Managed chronic illnesses- Monitored medications

Results attributed to:- Change embraced by physicians improve their skills- Data management, financial control, negotiation- Capital allocation provided for primary practice redesign

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Medical Home Frameworks

National Partnership of Women & Families (incl. AARP, ADA (Diabetes), NAACP, La Raza, etc.) publishes 9 Medical Home principles for patients- Set of principles from a diverse group to guide the development/implementation of the medical home

NCQA voluntary standards for physician practices as medical homes- Physician Practice Connections–Patient-Centered Medical Home (PPC-PCMH)

NEJM recommendations for medical home success- Share info. across HCPs, performance measures & shared savings payment model

AAAHC (Ambulatory Health Care) accrediting medical homes

AAFP medical home national demonstration project

JAMA – Patient Centered Medical Home (PCMH) cornerstones

Sources: http://www.nationalpartnership.org/site/DocServer/Advocate_Toolkit-Consumer_Principles_3-30-09.pdf?docID=4821, http://www.ncqa.org/tabid/631/Default.aspx, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729192/?tool=pmcentrez, http://www.aaahc.org/eweb/dynamicpage.aspx?webcode=mha, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2682981/?tool=pmcentrez, http://jama.ama-assn.org/cgi/content/full/301/19/2038

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Medical Home Solution Benchmarking

Current Medical Home Solution Evaluations & References- In Q1 2010 in the U.S., at least 26 pilot projects involving medical homes with external

payment reform being conducted in 18 states

Benchmarking examples- New Hampshire: CIGNA and Dartmouth-Hitchcock pilot with ~400 PCPs- Arizona: UnitedHealth with ~7,000 patients and 7 medical groups- New Jersey: Horizon BCBS pilot with 165 PCPs

Sources: Patient-Centered Primary Care Collaborative (retrieved from: http://www.pcpcc.net/content/pcpcc_pilot_report.pdf), Cigna (retrieved from http://newsroom.cigna.com/article_display.cfm?article_id=914), The New York Times (retrieved from: http://www.nytimes.com/2009/02/07/business/07medhome.html?_r=1)

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The Future of Information Technology in the Patient Centered Medical Home (PCMH)

EHRs need development of PCMH features to improve their efficiency, quality, and safety

Seven key health information technology domains identified as necessary for the success of the PCMH model- Chief of General Internal Medicine at Brigham & Women’s Hospital in Boston

Road map of the key domains:- 1) telehealth- 2) measurement of quality and efficiency- 3) care transitions- 4) personal health records- 5) registries- 6) team care- 7) clinical decision support for chronic diseases

Source: Health Affairs (retrieved from: http://content.healthaffairs.org/cgi/content/abstract/29/4/614)

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PCMH Implementation Recommendation

Phase 1: Caring for a defined population (list)- Defined list (patient panel, registered list) & responsibility for the list of patients- Ability to generate disease registries & ability to track requirements for effective

intervention- Provision for ‘ad hoc’ contacts (e.g., after hours phone, urgent-care / walk-in visits)

Phase 2: Delivering team-based care- Care delivered by a team (not all doctors) & all working at the top of their license- Same day access with delays in access will divert to other care locations

Phase 3: Redefining relationship to specialty care- Redefinition of role of specialists relative to primary care- Movement from just acute care to include secondary prevention (optimal management

of pre-existing health issues)

Phase 4: Shifting to delivering “health” rather than “disease care”- Effective primary prevention & connectivity to other community resources

Source: Institute for Healthcare Improvement 10/21/2010 (retrieved from: http://www.pcpcc.net/files/karen_boudreau.pdf)

In Summary, We Are Looking For Your Approval to Proceed to the Next Phase…

Phase II Approval- Launch of 18-month pilot program

- Establish governance process

- Initiate grant acquisition strategy

- Initiate IT analytics strategy

- Incremental initial investment needs:- Start-up cost of approximately $120,000 per physician- Additional Nurse Practitioner / PA resource- Additional Case Manager to manage 250-350 chronically ill patients

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MI 404 – Final Presentation

Q&A

Thank you!!

Chris DavisMarla Kouche

Ty Lee.

References

Abelson, R. (2009). UnitedHealth and I.B.M. Test Health Care Plan. The New York Times, February 6, 2009. Retrieved on November 7, 2010 from: http://www.nytimes.com/2009/02/07/business/07medhome.html?_r=1

Accreditation Association for Ambulatory Health Care (2010). Medical Home Accreditation. Retrieved on November 6, 2010 from: http://www.aaahc.org/eweb/dynamicpage.aspx?webcode=mha

American Hospital Association Committee on Research (2010). Patient-Centered Medical Home, AHA Research Synthesis Report (September 2010. Retrieved from: http://www.aha.org/aha/research-and-trends/cor.html

Bates, D., Bitton, A. (2010). The Future Of Health Information Technology In The Patient-Centered Medical Home. Health Affairs, 29, no. 4 (2010): 614-621. Retrieved on November 10, 2010 from:

http://content.healthaffairs.org/cgi/content/abstract/29/4/614

Bowman, D (2010). Medical home program leads to 'significant' cost savings, fewer hospitalizations. Fierce Healthcare (May 5, 2010). Retrieved on November 3, 2010 from: http://www.fiercehealthcare.com/story/medical- home-program-leads-significant-cost-savings-fewer-hospitalizations/2010-05-05)

Boudreau, K. (2010). The Triple Aim – Advancing Beyond the Medical Home. Institute for Healthcare Improvement, October 21, 2010. Retrieved October 28, 2010 from: http://www.pcpcc.net/files/karen_boudreau.pdf

Cassidy, A. (2010). Patient-Centered Medical Homes: A new way to deliver primary care may be more affordable and improve quality. But how widely adopted will the model be? Health Affairs/RWJF Health Policy Brief Series (September 14, 2010). Retrieved on November 15, 2010 from: http://www.rwjf.org/pr/product.jsp?id=68929

Fields, D., Leshen, E., Patel, K. (2010). Driving Quality Gains and Cost Savings through Adoption of Medical Homes. Health Affairs, 29, no. 5 (2010): 819-826

Fisher, E. (2008). Building a Medical Neighborhood for the Medical Home. New England Journal of Medicine (September 18, 2008) 359(12): 1202–1205. Retrieved on November 9, 2010 from:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729192/?tool=pmcentrez

Grundy, P., Rogers, E. (2008). Patient-Centered Medical Home Building Evidence and Momentum. Patient-Centered Primary Care Collaborative, 2008. Retrieved on November 8, 2010 from:

http://www.pcpcc.net/content/pcpcc_pilot_report.pdf

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References

Hardy, K. (2009). Study: Medical home model increases quality of care, reduces cost. Healthcare IT News (September 1, 2009). Retrieved on November 6,2010 from: http://www.healthcareitnews.com/news/study-medical-home-model-increases- quality-care-reduces-cost

National Committee for Quality Assurance (2010). Physician Practice Connections® - Patient-Centered Medical HomeTM. Retrieved on November 5, 2010 from: http://www.ncqa.org/tabid/631/Default.aspx

National Partnership for Women & Families (2010). Retrieved on November 5, 2010 from: http://www.nationalpartnership.org/site/DocServer/Advocate_Toolkit-Consumer_Principles_3-30-09.pdf?docID=4821

Nutting, P., Miller, W. (2009). Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home. Annals of Family Medicine, 2009 May; 7(3): 254–260. Retrieved on November 9, 2010 from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2682981/?tool=pmcentrez

Paulus, R., Davis, K., Steele, G. (2008). Continuous Innovation In Health Care-The Geisinger Experience. Health Affairs, 27, no. 5 (2008): 1235-1245

Rittenhouse, D., Shortell, S. (2010). The Patient-Centered Medical Home: Will It Stand the Test of Health Reform? The Journal of the American Medical Association, 2009; 301: 2038-2040. Retrieved on November 10, 2010 from:

http://jama.ama-assn.org/cgi/content/full/301/19/2038

Slitt, M., Mashaw-Gomeau, M., (2008). CIGNA and Dartmouth-Hitchcock Launch 'Patient-Centered Medical Home' Program to Provide Better Care Coordination. CIGNA Newsroom (June 10, 2008). Retrieved on November 8, 2010 from:

http://newsroom.cigna.com/article_display.cfm?article_id=914

Stange, K., Nutting, P., Miller, W., et al., (2010). Defining and measuring the patient-centered medical home. Journal of General Internal Medicine, 25(6), 601–12

Trapp, D. (2010). Medical Homes for Medicaid: The North Carolina Model. Amednews.com (August 2, 2010). Retrieved on October 12, 2010 from: http://www.ama-assn.org/amednews/2010/08/02/gvsa0802.htm

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