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Randy Cook, MPH, FACMPEPresident/CEO

Building Integrated Communities

of Care:PCMHs & ACOs

Marjie Harbrecht, MDCEO

Learning Objectives

1. Discover the high-leverage changes of PCMH’s to get results

2. Describe how PCMH’s can serve as the foundation of ACOs

3. Identify reimbursement payment programs that emphasize for “value” rather than “volume”

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U.S. Health Care

• Great Skills • Great Science• Poor Integration / Coordination

• Fragmented - Silos• Misaligned Incentives• Culture

What Do People Really Want?

• Trusting Relationship with Care Team • “I can reach someone who knows me, knows my history, can

advise me and cares about my issues”

• Service• “I can get care or contact with someone when I feel I need to,

without having to always come in”• “Less waiting in general” – during visits, for test results, for

referrals, for refills, etc.

• Reliable, Coordinated Care • “My care is coordinated” – between providers,

hospital/ER, home health, behavioral health, etc

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What Do We Want?

• Trusting Relationship with Our Patients, Colleagues and Staff

• Job Satisfaction • Provide the best, most efficient care possible• Make a difference in our patient’s lives

• Work-Life Balance

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PopulationHealth

Experienceof Care

Per CapitaCost

The Triple AimBy The Institute for Healthcare Improvement

The Triple AimBy The Institute for Healthcare Improvement

Déjà vu… All Over Again?

• Tremendous consolidation of market• What’s different from Managed Care days?

• Practice and community redesign• No-one taught us how before• Gatekeeper to Gateway• Better tools (Technology) to coordinate care• Patient sophistication and engagement

• Aligned incentives for ALL to work together• Quality – Affordability - Satisfaction

• Realization that no one can do this alone!

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Ideal State

• Shared “community” vision• Shared data – timely, actionable, in usable format

• Available at point of care • List of those needing services - for outreach• Aggregated across community to identify target areas

for improvement and monitor progress

• Shared Care Plans• Everyone that touches patient on the same page…

including the patient/family

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Patient-Centered Medical Home (PCMH)

An approach to providing high-quality, safe, continuous, coordinated,

comprehensive care, with a partnership between patients

and their personal health care team…

“The kind of care you’d

want your Mom to have!”

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BUILDING A SOLID FOUNDATIONFundamentals for Transforming

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Evidence-Based Medicine and Population Management

Technology, Data & Outcomes

Reporting

Patient Engagement &

Access

Care Mgmt, Coordination & Communication

Patient Centered Medical Homes

Leadership & Team Based

Care

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New payment modelsAllow a new way of thinking!

• Panel Management• Transition from FFS “Treadmill Medicine” to

coordinated planned management of entire panel, with extra care for those who need it

• Redefine “VISITS” – enhance access and convenience

• Help patients set goals – use teams to support them in achieving those goals

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Patient Centered Planned Care

• Before, During, and After Visit

• Develop Customized Care Plan• Shared-decision making• Prevention, Chronic Conditions, Acute Care Issues

• Warm Handover to Care Coordinator/Care Manager• Track tests/referrals, coordinate with medical

neighborhood, monitor registry/EMR• Engage patients, help them overcome barriers• Concentrate on high risk/high need patients

Prioritizing Care Management & Care Coordination

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Multiple Chronic

Conditions &

Complex Patients

A Medical Home Without An Integrated Medical Neighborhood

Is Just An Island

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Integrated Community Care

Provided Courtesy of Premier Healthcare Alliance

ACO Vs. PCMH

• A PCMH is a care delivery system• Primary Care (usually) • Help patients navigate system • Foundation for ACO

• An Accountable Care Organization (ACO)• A business structure under which multiple

providers (i.e., primary care, specialists, hospitals, etc) agree to care for a particular population of patients and be accountable for quality, cost, experience of care.

TOP DOWN - BOTTOM UP

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US0

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40

60

80

100

31 30

4953

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25

3632

2015

33

41

49

57 59

42 41

51

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3033

54

Medical home No medical home

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Coordination Gaps With and Without Medical Homes

Percent*

Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Building The Medical Neighborhood

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• Specialists (PCMH-N)– ACP Framework and Compacts; NCQA

• Hospitals– Identification, Notification, Communication

• Mental/Behavioral Health– Overcoming HIPAA, Carve Outs

• Shared Resources – Expanded “TEAM”• Complex Care Managers, Clinical Pharmacists,

Social Workers, Educators, Mental Health Providers, Home Health…

• Community Resources– Awareness and Connections

Reasons Why This Ain’t Been Easy

• The typical primary care physician has 229 other physicians working in 117 practices with which care must be coordinated. Pham et. al Ann Int Med. 2009

• In the Medicare population, the average beneficiary sees seven different physicians and fills upwards of 20 prescriptions per year Partnership for Solutions, Johns Hopkins Univ. 2002

Tactics Versus Culture

“Culture eats strategy for lunch…over and over again.”

IT’S ALL ABOUT TEAM!!

When Teams Don’t Work Well…

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U.S. Men's Basketball Falls Flat on World StageBy David DuPree, USA TODAYAugust 15, 2004

 ATHENS-

“This is the Olympics, and the U.S. men's basketball team was rocked, shocked, humiliated and exposed on sports biggest stage Sunday as Puerto Rico, a Commonwealth of 4 million residents, pulled off the upset of all Olympic upsets with a 92-73 drubbing of the Americans.”

Most SKILLED players in the world - What went wrong??

GREAT PLAYERS vs. GREAT TEAM

Individual Choice VS Team Efficiency

REALLY??

When Teams Work Well…

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First Step: Create Your Shared Vision

Identify Pain Points – Work Toward Solutions and Common Goals

• Mutual respect of what each brings to the table

• Recognition of the value of role differentiation

• Acknowledgement of a flawed system

• Clarifying misconceptions

• Striving for “professionalism”• Better communication, consideration, cooperation

Always return to: Patient-Centered Care

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Investment Required to Reduce CHAOS and Build Solid Infrastructure

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IT’S ALL ABOUT RELATIONSHIPS!!

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With Our TEAMS

Building Accountability to Each Other and Our Communities

With Our NEIGHBORSWith Our PATIENTS!

The Market is Changing

• Fee-for-service (FFS) is in decline

• Fee-for-quality (FFQ) is increasing

• Opposite incentives

• The problem is the transition

Time ==>

Payment for Units (FFS)

Payment for Quality (FFQ)

Time ==>

Payment for Units (FFS)

Payment for Quality (FFQ)

The Market is Changing

Time ==>

Payment for Units (FFS)

Payment for Quality (FFQ)

The Market is Changing

ACOs – Getting Paid For Value

• ACOs are one, among others, method of getting paid for value

• Generate savings and Medicare returns ½• 10 PCPs could earn $6 + million in shared

savings• Lots of types of ACOs but all are based on

PCPs• A PCMH has a leg up on the opportunity to

create savings

Getting Paid As A PCMH

• Getting paid is principle # 8• A PCMH creating its own ACO is one way• Other methods

• Pay for performance (P4P)• Capitation (Not PCP capitation)• Gain sharing agreements• Fee-For-Service Add-ons

Pay for Performance - Measures

• Cost / utilization thresholds• ER visit rates• Readmission rates• Cost of targeted types of care• Generic scripts percent

• Quality measures (Process)• % of Diabetic patients whose HbA1c has been tested• % of CHF patients whose LDL has been tested• % of Hypertension patients whose BP has been checked

• Quality measures (Outcome)• % of Diabetic patients whose HbA1c is under control• % of CHF patients on ACE/ARB therapy• % of Hypertension patients with BP <140/90

Pay For Performance - Payment

• Bonuses earned for each measure achieved• Bonuses paid as a percent of fees paid• Future fee schedules set based on

performance• More complex measures

• Groups of providers• Measures dependent on actions of multiple

providers

Capitation

• Fixed payment based on population, NOT the services that are required

• PCP capitation is contrary to PCMH philosophy• Underwriting risk and operational risk

• Adverse selection• Responsibility for payments to providers

• Pros: • All savings accrue to the capitated provider• Price per unit is available as a cost savings variable

• Cons:• New critical requirements, before you manage cost• The risk of negatively influencing quality

Gain / Loss Sharing• A budget is agreed and actual expenses are compared• Savings (and maybe losses) are shared• Underwriting risk remains, but not operational risk

• Pros:• Plan

administers payments and pools risk

• Gain side only is possible & losses are shared

• Cons:• Price per unit is

not available as a variable

• Savings must be shared

Fee-For-Service Add-ons

• Case management fees• Fixed PMPM payment for PCMH activity, over Fee-

for-Service

• Case management service• Plan provides a case

manager to collect data and perform selected functions

Summary

• ACO = Payment model (Government or Commercial)

• PCMH = Delivery system, regardless of payment model

• PCMH built around 8 principles

• PCMH provides value to the market

• Several ways PCMH can get paid

QUESTIONS?

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