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talk to the office of the national coordinator health information technology in Atlanta Georgia in July of 2011
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Reinventing Medicaid findings are Outstanding Oklahoma's patient-centered medical home initiative
has reduced Medicaid costs $29 per patient per year from 2008 to 2010. Moreover, use of evidence-based primary care, including screening for breast and cervical cancer, increased.
The Colorado initiative expanded access to care. Before the initiative, only 20 percent of pediatricians in the state accepted Medicaid; as of 2010, 96 percent and did and at a lower cost to the state.
Vermont, inpatient care use and related per-person per-month costs decreased 21 percent and 22 percent, respectively, from July 2008 to October 2010. ER use and related per-person per-month costs decreased 31 percent and 36 percent, respectively.
Patient Centered Medical Home in Washington in State Acute care spending there was 18 percent below the national average. Inpatient stays per beneficiary were 35 percent below the national average.
Citation -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results," Health Affairs, July 2011 30(7):1325–34.
The Bottom Line in Medicaid PCMH starting to show an impact in access to care, quality, and cost control .
Out in July 2011
BCBS MA 6% decrees cost (NEJM) BCBS Mi 2670 physician (BIG study)
2010 2011
Adults (18-64)
ER visits -6.6% -9.9%Primary care sensitive ER Visits -7.0% -11.4%Ambulatory care sensitive Hospitalizations (per 1,000) -11.1% -22.0%
MGMA: 70% of Practices at Least Interested in Becoming Patient Centered Medical Homes
13 to 20 % are already on the road Some states Michigan, Minnesota, Maryland,
RI, VT 50% already are well on the road !! Standard of care in the VA, DOD IBM $ 60 per Member BCBS HI 14.6% ^
Outside Hospital video clip
Who was the Shooter’s Doctor?
Population managementAccountability
$10,743
$28,530
+166%
Why Innovate Affordability
Costs continue their upward climb…
…with employers still picking up much of the tab…
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
a- Employer Cost - Employee Payroll Contributions - Employee Out of Pocket Expenses
2001 2009 2019
$4,918
+118%
The Elephant in the room
Health care is a business issue, not a benefits issue
The Cause? Mostly due to unregulated fee-for-service payments and an over reliance on rescue/specialty care. This is stark evidence that the U.S. health care Industry has been failing us for years “Commonly cited causes for the nation's poor performance are not to blame - it is the failure of the deliver system!!”
You the AHC’s - Unaccountable Care Organizations PART of this problem
* Peter A. Muennig and Sherry A. Glied Health Affairs Oct. 7, 2010
Don’t handle your care needs in a BAD MEDICAL NEIGHBORHOOD!!
Unaccountable care, lack of organization, DO NOT GO THERE ALONE !!
Be wise when you pay for care, KNOW WHAT YOU BUY!!
“ We don't have a health care delivery system in this country. We have an expensive plethora of uncoordinated, unlinked, micro systems, each performing in ways that too often create sub-optimal performance, both for the overall health care infrastructure and for individual patients." George Halvorson, from “Healthcare Reform Now
Coordination -- we do NOT know how to play as a team
“We do kidney transplants and dialysis more often than anyone, but we need to, because patients are not given the kind of coordinated primary care that would prevent chronic complications of renal and heart disease from becoming acute.”
George Halvorson (CEO Kaiser) from “Healthcare Reform Now”
The Diabetic needs A long-term comprehensive relationship with a Personal Physician empowered
with the right tools and linked to their care team.
The Joint Principles: Patient Centered Medical Home Personal physician - each patient has an ongoing relationship with a personal
physician trained to provide first contact, and continuous and comprehensive care Physician directed medical practice – the personal physician leads a team of
individuals at the practice level who collectively take responsibility for the ongoing care of patients
Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or arranging care with other qualified professionals
Care is coordinated and integrated across all elements of the complex healthcare community- coordination is enabled by registries, information technology, and health information exchanges
Quality and safety are hallmarks of the medical home-
Evidence-based medicine and clinical decision-support tools guide decision-making; Physicians in the practice accept accountability voluntary engagement in performance measurement and improvement
Enhanced access to care is available - systems such as open scheduling, expanded hours, and new communication paths between patients, their personal physician, and practice staff are used
Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home- providers and employers work together to achieve payment reform
14
PopulationHealth
System Integrator
PatientExperience
The System Integrator
Creates a partnership across the medical
neighborhood
Drives PCMH primary care redesign
Offers a utility for population health and financial management
Per Capita Cost
Productivity
The Quadruple AimReadiness, Experience of Care, Population Health,
Cost
• For Diabetes you need a Captain for the ship
• You need a place of command and control
• You need a horizontal platform from which to launch vertical weapon systems
• You need somewhere and someone to hold accountable
So simple!So much!
If you scan the world for value based healthcare, you will find a common element: a relationship-based team with a project manager! A comprehensivist that can command and control in an accountable system.
Patientis the center
of theMedical Home
Population Health
Patient-Centered
Care
Refocused Medical TrainingPatient &
Physician Feedback
Advanced IT Systems
Access to Care
Team-Based Healthcare
Delivery
Decision Support Tools
Model adapted from theNNMC Medical Home
Enhancing Health and the Patient Experience
Medical Home Model
Superb Access to Care
Patient Engagement in Care
Clinical Information Systems
Care Coordination
Team Care
Patient Feedback
Publically Available Information
Defining the Care Centered on Patient
36.3% Drop in hospital days32.2% Drop in ER use 9.6% Total cost 10.5% Inpatient specialty care costs are down18.9% Ancillary costs down 15.0% Outpatient specialty down
Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US, K. Grumbach & P. Grundy, November 16th 2010
Smarter Healthcare…
Patient Centered Medical Home in Washington in State provided great example of how states can lower spending by reducing hospital care and expanding access to primary care providers. Acute care spending there was 18 percent below the national average. Inpatient stays per beneficiary were 35 percent below the national average.
Ref Health Affairs 7 July 2011 .http://healthaffairs.org/blog/2011/07/07/medicaid-spending-variations-driven-more-by-volume-than-price-says-study-in-new-health-affairs/ http://content.healthaffairs.org/content/30/7/1316.full
OPM $39 Billion Book with Accountable CarePatient at the center
24-7 clinician phone response Provide open scheduling. Provide care management and
coordination by specially-trained team members.
Use an EHR with decision support. Use CPOE for all orders, test
tracking, and follow-up. Medication reconciliation for every
visit. Prescription drug decision support. Implement e-prescribing.
Pre-visit planning and after-visit follow-up for care management.
Offer patient self-management support.
Provide a visit summary to the patient following each visit.
Maintain a summary-of-care record for patient transitions.
Email consultations. Telephone consultations. The development of care
plans. Performance outcome measures.
Public Health Prevention
Specialists
PCMH in Action Vermont “Blueprint” model
Community Care Team
Nurse CoordinatorSocial Workers
DieticiansCommunity Health Workers
Care Coordinators
Public Health Prevention HEALTH WELLNESS
Hospitals
PCMH
PCMH
Health IT Framework
Global Information Framework
Evaluation Framework
Operations
A Coordinated Health System
1 2 3 4 5$300,000,000
$320,000,000
$340,000,000
$360,000,000
$380,000,000
$400,000,000
$420,000,000
IMPACT OF MEDICAL HOME SAVINGS ACROSS TOTAL POPULATION
YEARS
INC
RE
ME
NT
AL
CO
ST
P
ER
YE
AR
Vermont Financial Impact
Payment reform requires more than one method, you have dials, adjust
them!!!fee for health”
“fee for outcome”
“fee for process” “fee for belonging
“fee for service”
“fee for satisfaction”
Reinventing Medicaid: State PCMH Innovations Show Promising Results New Payment Incentives – 17 states evaluated
Monthly care management fees. Most of the states studied pay patient-centered medical homes a per-member per-month fee averaging about $3 to $6. PAY FOR HIT Meaningful USE
Enhanced fee-for-service payments. Medicaid strategy rewards "well care" more highly than "sick care."
Network payments. North Carolina and Vermont pay networks or teams to support patient-centered medical homes.
Pay-for-performance. Nebraska, Oklahoma, and Pennsylvania are using performance-based payments. to complement other payments to patient-centered medical homes. Pennsylvania practices that have met certain performance criteria can share in any savings they generate.
Medicaid plans and commercial insurers. Seventeen states are participating or plan to participate in multipayer patient-centered medical home initiatives. Eight will add Medicare as a payer in 2011
Citation -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results," Health Affairs, July 2011 30(7):1325–34.
Care Coordination Payments To Practices In State Patient-Centered Medical Home Initiatives
Initiative PaymentAdjusted for patient
Adjusted for medical home level
Enhanced payment to practiceMedicaid managed care organizations
Iowa: IowaCare Medical Home Model $1.50–$3.00 No Yes Yes, based on performance No
Maine: Patient-Centered Medical Home Pilota $3.00–$7.00b No No No No
Maryland: Patient Centered Medical Home Pilot $4.68–$8.66c Yes Yes Yes, based on performance Yes
Massachusetts: Patient-Centered Medical Home Initiative $2.10–$7.50 Yes No Yes, lump sum based on performance Yes
Michigan: Primary Care Transformation Demonstration Projecta $3.00–$4.50 Yes No Yes, based on performance Yes
Minnesota: Health Care Homes Programa $10.14–$79.05d Yes No No Yes
Nebraska: Medicaid Medical Home Pilot Program $2.00–$4.00 No Yes Yes, based on performance No
New York: Adirondack Medical Home Demonstration Projecta $3.50 No No No Yes
North Carolina: Community Care of North Carolinaa,e $2.50–$5.00 Yes To be determined No No
Oklahoma: SoonerCare Choice $2.93–$8.41 Yes Yes Yes, lump sum based on performance No
Pennsylvania: Chronic Care Initiativea $3.00–$8.50f Yes Yes Yes, lump sum based on performance Yes
Rhode Island: Chronic Care Sustainability Initiativea $3.00 No NoYes, lump sum based on hiring a nurse care manager Yes
Vermont: Blueprint for Healtha $1.20–$2.39 No Yes Variesg Yes
Washington: Multi-PayerMedical Home Reimbursement Pilot $2.00–$2.50 No No Yes, based on performance Yes
• SOURCE Author’s analysis of state government information. NOTES The
Physician Practice Size
(# of patients) Level 1+ Level 2+ Level 3+
< 10,000 $4.68 $5.34 $6.01
10,000 - 20,000 $3.90 $4.45 $5.01
> 20,000 $3.51 $4.01 $4.51
PMPM Payment: Commercial Population
Level of PCMH Recognition
28
Tier Major Condition Groups Minutes of Work PMPM PMPM Payment
0 None N/ A N/ A
1 3-Jan 15 $10.14
2 6-Apr 30 $20.27
3 9-Jul 60 $40.54
4 10+ 90 $60.81
PCMH is non-political – the right POV for delivery transformation
“We never abandoned advocating newModels of care. We’ve long pushed folksto realize that Delivery reform is the key.”The patient-centered medical home iscore.
“We included the attached chapter on PCMH in our book. and have a new publication on ACOs coming out in January.”
Where do you train the Workforce?
OR?
…Requires a Smarter Healthcare Workforce
Basic
Descriptive Analytics
Performance Metrics
Advanced Analytics
Intelligent
BreakawayPassionate sponsor
of analytics
Pride in the gut based decision
Significant manual input
Predictive modeling
Contextual business
rulesData warehouses, governance and production reporting
Isolated reporting & analysis systems
Integrated information
Leverage cross- departmental &
functional data to derive actionable
insight
Performance messages widely communicated
Single version of truth
Personalized & role based
portal
Operational buy-in to performance analysis
driving decisionsRobust feedback loop
Analytics embraced & integrated into every day decisions & operations
Collaboration & workflow tools to aid planning & info sharing
Communication & Culture
Monitoring, Prediction,
ActionAutomated
analysis/alert
Leverage structured & unstructured
data for decision making
Real-Time Decision Support
Test and LearnCulture
Analytics Maturity Landscape
Spreadsheets
Adaptive Machine Learning
Patients love to see meaningful information about themselves and it take IT tools to
If you give patients educational materials with their name on it and with their data analyzed in it, they will read it, pour over it and discuss it with you.
If you tear off a generic sheet and give it to them, it often goes in the waste basket. If you give patients an analysis of their health risk AND if you include a “what if” scenario, i.e., what will their health risk be if they make a change; you can prove to them,
“if you the healer make a change, it will make a difference to your patient.”
• Build the foundation, the horizontal platform, a place of accountability – PCMH that allows HIT to be paid for.
• Really engage your patients find out what they need and become very patient centered
• Integrate value base purchasing with PCMH in your plan designee (understand what the buyer wants)
• Stop teaching the past you are in a world of Data, teams, actionable information
• Integrate Health and Sick care
• GIVE US LEADERSHIP - SHOW US THE WAY!
Recommendations
35
Payment Model Component PMPM Payment
Care management payments Up to $2.50 PMPM
Pay-for-performance payments Up to $2.50 PMPM
Payment Model Component PMPM Payment
Practice transformation cost payments (year 1 only)
$1.67 PMPM
Performance bonus (beginning in year 2) Up to $2.38 PMPM (value based on performance)
Risk-adjustment Up to $1.67 PMPM (only for practices with above average patient panel risk profiles; amount varies by practice)
Payment Model Component PMPM Payment
Practice support payments $1.50 PMPM
$0.60 PMPM (ages 0-17)
$1.50 PMPM (ages 18-64)
$5.00 PMPM (ages 65-74)
$7.00 PMPM (ages 75+)
Shared savings Value based on performance
Care management payments
I) if quality care exists in your community, use it2) Demand improved primary care (and be willing to pay for the transformation if in the long run it saves you Money and it does it) Communities need to be taught how to recruit and retain a primary care physician. There is a lot of work that has been done on this. 3) Seek out and use “Patient Centered Medical Homes” for health care4) Find physicians who are trying to conquered the digital divide5) Find a doctor comfortable with moving into the future with data, populating management, 6) Demand a focus on quality7) Demand provides in your community to collaborate, collaborate, collaborateIf there is a community health center (CHC), a rural health clinic, and a critical access (or small rural hospital) in your community, encourage collaboration8) Encourage mental health and primary care to work together (the Brain is connected to the body) 9) Work to build a healthy community integrate health and sick care