The Patient Center Medical Home: Is it the future?

Mark B. Mengel, MD, MPHVice-Chancellor, Regional Programs

June 15th, 2012(Some of these slides were borrowed from presentations provided by Dr. James McConnell, OHSU, Dr. Joseph

Thompson, ACHI, Becky Hall, (Delta-AHEC), Pat Vannatta, (AHEC Central), Dr. Robert Gabbay, Penn State Hershey Diabetes Institute, the Advisory Board, and Dr. James Marsh, (UAMS)

Thanks

• Bob Price, Ph.D. and his team at the Central Office

• AHEC PCMH teams• AHEC Clinical Leadership Council• Sterling Moore, Jessica Ellis, AHEC business

managers, and our back office folks who continuously improve our practice management operations

AHEC PCMH Goals

• By the end of June 2012, be able to achieve level II NCQA accreditation.

• By the end of December 2013, be able to achieve level III NCQA accreditation.*

*Will be accelerated if we participate in the CPCI CMS innovation grant.

We Need a Better System of Care:The Patient Centered Medical Home

The time barrier in primary care

• 10.6 hours-amount of time it would take the average primary care doctor to provide all evidence-based chronic disease care to an average panel of 2,500 patients, (10 most common chronic diseases)

• 7.4 hours-preventive care• 4.6 hours-acute care• 22.6 hours-total, (that does leave 1.4 hours for

sleep!)References: 1. Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3(3):209-214.2. Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93(4):635–641.3. Stange KC, Zyzanski SJ, Jaén CR, et al. Illuminating the ‘black box’. A description of 4454 patient visits to 138 family physicians. J Fam Pract. 1998;46(5):377–389.

Today: Providing Care for the Sick

Tomorrow: Keeping Patients HealthyMulti-Disciplinary Team

TransforMed Learnings

• PCMH is a transformation of a practice, (3 to 5 years), not a small incremental change

• Requires capability for organizational learning and development, (Leadership is key!)

• Change in relationships, (with patients, staff, other providers)

• Supportive health care neighborhood • Reimbursement model changes-care

management fees and shared savings

Strengthening Primary Care and Care Coordination in Medicare: Distribution of 10-Year Impact on Spending

-$9.1

-$193.5-$156.9

-$4.1-$23.4

-$250

-$200

-$150

-$100

-$50

$0

$50

$100

Systemwide FederalGov't

State andLocal Gov't

PrivatePayer

Households

Source: C. Schoen et al., Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending, The Commonwealth Fund, December 2008.

Dollars in billions

SAVI

NGS

COST

S

2002 2003 2004 2005 2006 2007 2008 2009 20100.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

11.5%

2.5%

17.0%

3.7%

12.7%

8.8%

Annual Percent Change in Medicaid Expenditures2002 - 2010

North Carolina Georgia National Average - Kaiser Commission Study

Georgia imple-ments managed

care

CCNC Implements ABD Program

CCNC expands across North Carolina starting in 1998. Between 2002 and 2005 expansion increased from 17 to 93 counties. By 2007, all 100 counties were under the CCNC umbrella organization.

Clinical Process ImprovementStatewide Quality Improvement

(n= 140 practices)Diabetes Measures Average Abs. %

Difference:Foot Exam +26%Eye Exam +12%Diabetic Nephropathy +18%Self-Management Goal Setting

+32%

Clinical Outcomes ImprovementIMPROVED CLINICAL OUTCOMES

(n= 140 practices)

Diabetes Measures Average Abs % Change

BP <130/80 +7%BP <140/90 +13%LDL <100 +6%LDL <130 +11%HbA1C >9% -5%HbA1C <7% +7%

AHEC PCMH Costs

• Decreased productivity• Additional Team members not currently

present• Purchase and on-going operational costs of

EMR’s and other IT tools• Time for staff to meet to design and

implement new workflows• Education and marketing to patients

AHEC PCMH IT Costs

• Initial purchase and license fees; lost productivity; training and consultants; server virtualization: $3,487,6000 (can offset with meaningful use money-AHEC estimate: $3,264,750)

• Annual maintenance and IT personal costs: $703,316

Additional Team Members

• Health Psychologist (1)• PCMH Nurse Coordinator (1)• Medical Assistants or Care Coordinators (2 or 3)• Outreach Workers (2 or 3)• Central Office support: IT Project Manager (1), RN Case

Manager (3), Nutritionist (1)• (AHEC’s have NP’s, except AHEC-NE, and Pharmacists,

already.)• TOTAL AHEC Annual Implementation Costs: $3,164,438.

(For the Equivalent of 35.96 FTE Providers in our FMC’s.)

Total PCMH annual costs

• $703,316 + $3,164,438=$3,867,754.• Per AHEC: $644,625• Per FTE Provider: $107,437

Estimated PCMH incremental costs

• $100,000-$115,000 per primary care clinician, • $78,000 per health coach; 56 percent load for

coaching tools (data collection, telephones, IT systems, etc.);

• 33 percent FTE data manager at $65,000 per data manager;

• and $5,000-$20,000 for health IT and Web site technical support annual maintenance.

*Deloitte Center for Health Solutions. The Medical Home: Disruptive Innovation for a new Primary Care Model. 2008.

Figure 2: Vision for 21st Century Health Care Delivery in Arkansas

CMS Innovation Center’s Comprehensive Primary Care Initiative

• 7 Markets selected, AR (state-wide) included• Insurance involved: Medicare, Medicaid, QualChoice, and

Blue Cross and Blue Shield• 4 year pilot project of 75 adult primary care practices in

Arkansas– EMR– 150 eligible Medicare beneficiaries– 60% of revenues generated by payers participating– Level 1 MU perfered; NCQA PCMH level 1, 2, or 3 preferred or

document performance of comprehensive primary care functions

Comprehensive Primary Care Functions

• Risk-stratified case management• Access and continuity• Planned care for chronic conditions and

prevention care• Patient and care giver engagement• Coordination of care across the medical

neighborhood

CPCI Case Management Fees• Medicare: Average $20 per patient per month first two year,

risk adjusted. Decrease to $15 on average in year 3 and 4.• Medicaid: preliminary estimate $7 per patient per month,

not risk adjusted, includes kids.• QualChoice: $3 per patient per month, not risk adjusted.• Blue Cross and Blue Shield: $5 per patient per month, not

risk adjusted.• SHARED SAVINGS: Only in year 3 and 4, no rules, yet.• CONCLUSION: Only Medicare will cover PCMH capacity

costs.

Are others on the PCMH train?

• Recent MGMA survey: 36% of FM practices moving toward PCMH

• Recent MGMA survey: 20% of practices, including multispec groups, have achieved PCMH NCQA accrediation

• Ark BCBS pilots (7)• UAMS Center for Primary Care: PCMH’s in FM,

Gen IM, and Geriatrics (along with Smart Care).

NEJM | March 30, 2011 |

It’s already starting

NEJM | March 30, 2011 |

CURRENT AND EXPECTED VACANCIES FOR PRIMARY CARE PHYSICIANS IN ARKANSAS, 2011

Family PracticeInternal Medicine

PediatricsOBGYN

0

50

100

150

200

250

300

350

400

450

500

282

104

89

36

473

176

125

87

Current

5 Year

Closing thought

31

“Making systems work in health care-shifting from corralling cowboys to producing pit crews-is the great task of your and my generation of clinician and scientists.”

Atul Gawande, M.D.Harvard Medical School

CommencementMay 26, 2011