building new york's medical homes

November 2012

Authored by Daniel Lowenstein, MBA

Therese Wetterman, MPH

Cecilia Dougherty

BuildingNewYork’sMedicalHomes

Learning from Eight Pioneers to Move the Model Forward

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TableofContents

ACKNOWLEDGEMENTS .......................................................................................................................... 2

ABOUT THE PRIMARY CARE DEVELOPMENT CORPORATION ......................................................................... 2

GLOSSARY OF TERMS ............................................................................................................................ 3

EXECUTIVE SUMMARY ........................................................................................................................... 4

OVERVIEW .......................................................................................................................................... 6

EVIDENCE OF IMPROVED CLINICAL QUALITY AND ACCESS ARE EMERGING .................................................... 7

PCMH IMPACT ON LONG TERM COST SAVINGS AS YET UNCLEAR ............................................................... 7

ON THE ROAD TO PAY‐FOR‐PERFORMANCE ........................................................................................... 7

DATA CHALLENGES COMPLICATE PROGRESS .......................................................................................... 8

NCQA RECOGNITION: AN ELEMENT OF TRANSFORMATION ...................................................................... 9

LEADERSHIP AND COLLABORATION IS CRITICAL ....................................................................................... 9

PCMH TRAINING NEEDED AT ALL LEVELS ............................................................................................ 10

BUILDING ON THE PCMH FOUNDATION ............................................................................................. 10

THE ADIRONDACK MEDICAL HOME DEMONSTRATION (AMHD) ................................................................ 11

CAPITAL DISTRICT PHYSICIANS’ HEALTH PLAN (CDPHP) ENHANCED PRIMARY CARE INITIATIVE ...................... 15

CRYSTAL RUN HEALTHCARE ................................................................................................................. 18

EMPIRE BLUE CROSS/BLUE SHIELD MEDICAL HOME DEMONSTRATION ....................................................... 21

EXCELLUS AND MVP ROCHESTER MEDICAL HOME INITIATIVE.................................................................... 24

NEW YORK STATE DEPARTMENT OF HEALTH PCMH MEDICAID INCENTIVE PROGRAM .................................. 27

NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE PRIMARY CARE INFORMATION PROJECT ...... 30

P2 COLLABORATIVE OF WESTERN NEW YORK .......................................................................................... 33

WORKS CITED AND ADDITIONAL RESOURCES……………………………………………………………………………..……36

2

Acknowledgements

NYS Medical Home Conference Planning Committee –James Tallon, David Gould, Greg Burke (United

Hospital Fund): Linda Lambert, Lisa Noel (American College of Physicians, New York State Chapter);

Melinda Abrams, Karen Crow (The Commonwealth Fund); Foster Gesten, MD (NYS Department of Health);

John Rugge, MD (Hudson Headwaters Healthcare Network/Adirondack Medical Home Demonstration);

Ronda Kotelchuck (Primary Care Development Corporation).

Interview Participants ‐ Cathy Homkey, Cynthia Nassivera‐Reynolds, Bob Cawley (Adirondack Medical

Home Demonstration); Lisa Sasko (Capital District Physicians Health Plan); Hal Teitelbaum, MD, JD, MBA,

Gregory Spencer, MD, Scott Hines, MD, Jon Nasser, MD, Betty Jessup (Crystal Run Healthcare); John Caby,

Scott Breidbart, MD, Philip Thomas (Empire Blue Cross/Blue Shield); Martin Lustick, MD (Excellus

Blue Cross/Blue Shield); Foster Gesten, MD, Marietta Angelotti, MD, Lindsay Cogan (New York State

Department of Health); Amanda Parsons, MD, Elizabeth Wolff, MD, MPA, Sharah Shih, MPH (Primary Care

Information Project, New York City Department of Health and Mental Hygiene); Shelley Hirshberg, Kate

Ebersole (P2 Collaborative of Western New York)

This publication was made possible with support from The Shelley and Donald Rubin Foundation.

About the Primary Care Development Corporation

The Primary Care Development Corporation (PCDC) is a nonprofit organization dedicated to ensuring that

every community has timely and effective access to high‐quality, patient‐centered primary health care. Our

programs expand access to primary care through affordable financing to build and modernize facilities;

coaching and training to improve primary care delivery; and policy and advocacy to ensure strong policies

that strengthen the primary care sector.

PCDC has helped nearly 100 primary care practices become recognized medical homes, and has worked

with hundreds of practices to expand access to patient‐centered primary care, including reducing patient

wait‐times, adopting electronic medical records, and operating with sound business practices to better

serve patients.

For more information, please visit www.pcdc.org.

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Glossary of Terms Author’s Note: This publication assumes the reader has a working knowledge of the Patient‐Centered Medical

Home and the primary care delivery system.

A1C common blood test used to determine how well diabetes is being controlled

ACA Affordable Care Act

AHRQ Agency for Healthcare Research and Quality

ARRA American Recovery and Reinvestment Act (aka “stimulus”)

CAHPS Consumer Assessment of Healthcare Providers and Systems, a multi‐year initiative of

AHRQ to support and promote the assessment of consumers' experiences with health care

CMMI Center for Medicare and Medicaid Innovation, a CMS center established by the ACA to

identify, develop, support, and evaluate innovative models of payment and care service

delivery for Medicare, Medicaid and CHIP beneficiaries

CMS Center for Medicare and Medicaid Services

EHR Electronic Health Record

FFS Fee for Service, a payment method where providers are reimbursed for each service

provided to the patient

Health Home An ACA‐supported initiative to provide care coordination to high‐cost Medicaid patients

with multiple chronic conditions

HEDIS Healthcare Effectiveness Data and Information Set – a set of quality measures established

by NCQA and widely applied to health plans

MU Meaningful Use, a financial incentive program under ARRA supporting physician adoption

of electronic health records

NCQA National Committee on Quality Assurance, a non‐profit organization which has developed

quality standards and measures for health plan and primary care performance

NYCDOHMH New York City Department of Health and Mental Hygiene

NYSDOH New York State Department of Health

PCMH Patient Centered Medical Home

PMPM Per‐Member Per‐Month, a payment method where providers received a fixed amount per

patient per month

Recognition NCQA “recognizes” providers at PCMH Levels 1, 2 or 3

Triple Aim A framework developed by the Institute for Healthcare Improvement that includes improving patient experience of care, improving health of populations, and reducing per capita cost of health care.

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Executive Summary

Through our work, PCDC has found that when implemented effectively, a true PCMH model of care can

improve health outcomes and control health care costs by delivering healthcare services in a way that puts

the patient at the center of his or her care. However, it is also clear that PCMH transformation can be

intensive and complex, particularly for safety‐net and small practice settings. The PCMH journey is defined

by a continual process that requires constant assessment and evaluation, continuous improvements in

workflows and processes, and enduring organizational capacity for change.

Over the past four years, New York State has made considerable progress in the expansion of the Patient

Centered Medical Home (PCMH), including the development and evolution of a number of important PCMH

pilots and initiatives. As part of an effort to assess the current PCMH environment in New York and better

understand the challenges to expanding and sustaining patient‐centered models of care delivery and

payment, PCDC conducted interviews with the leadership of eight such initiatives across the state:

Adirondack Medical Home Demonstration (AMHD), Capital District Physicians Health Plan Medical Home

Pilot (CDPHP), Crystal Run Healthcare, Empire Blue Cross/Blue Shield (Empire), Excellus and MVP Rochester

Medical Home Initiative (interviewed Excellus), New York State Department of Health PCMH Medicaid

Incentive Program (NYSDOH), Patient Centered Information Project (PCIP), and P2 Collaborative of Western

New York.

Interviews and additional background research identified the following common themes:

Evidence of improved clinical quality and access is emerging: All of the initiatives saw evidence

of improved clinical quality that was likely linked to PCMH‐related improvements;

Long term cost savings is as yet unclear: For most of the initiatives, it was still too early to tell

whether PCMH activities would lead to long term cost savings;

Payment is evolving to Pay‐for‐Performance: Regardless of how payment is currently made,

there is movement toward a pay‐for‐performance model that sufficiently and sustainably covers

the costs of PCMH;

Data challenges complicate progress: There is widespread concern about the availability,

accuracy, validity, and completeness of data; these challenges become more prominent when

larger numbers of stakeholders are involved in the PCMH initiative;

NCQA PCMH recognition is one element of transformation: Rather than an end goal, NCQA

PCMH recognition was seen as an important element of the transformation process;

Leadership and collaboration is critical: Practice‐level leadership was viewed as essential to

successful PCMH implementation, and for those operating PCMH initiatives across practices

(and/or payers), collaboration was key to getting disparate providers and payers to work

together towards common goals;

More training is needed at all levels: More personnel at all levels need to be trained and attuned

to the tenets of PCMH and retaining individuals with critical thinking, collaboration and team

skills was seen as seen as necessary for sustaining PCMH; care management personnel were in

short supply and high demand.

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PCMH prepares for the next stages in healthcare evolution: Finally, regardless of the challenges,

the process of transforming, collaborating and risk‐taking prepared all of the initiatives for the

next stage in a fast‐evolving healthcare environment.

Profiles of the eight PCMH initiatives follow the overview and focus on the specific challenges and goals as

told by the initiative’s leadership. There are many more PCMH initiatives undertaking innovative and

important work throughout New York State – some in the same region as those profiled in the study. The

eight selected represent diversity in geography, populations served, payment methodology, and leadership

type. No distinction should be drawn regarding the quality or value of those profiled versus those that were

not.

This paper, along with a companion analysis of Patient Centered Medical Home (PCMH) recognition trends

in New York State conducted by the United Hospital Fund, was prepared for the Fall 2012 Fall conference:

Moving New York’s Patient Centered Medical Home Forward: Spread and Sustainability. (The conference

was postponed due to storm related complications). The Primary Care Development Corporation (PCDC)

joined with leadership from United Hospital Fund, American College of Physicians (NYS Chapter), NYS

Department of Health, the Commonwealth Fund, and the Adirondack Medical Home Demonstration to

convene this conference of stakeholders to further PCMH expansion in New York State.

We hope that this effort sheds light on New York’s PCMH enterprise, and helps to advance efforts to

expand and sustain PCMH to achieve the Triple Aim of better patient experience, healthier communities

and lower per‐patient health costs.

6Overview

Overview

Over the past four years, New York State has made considerable progress in the expansion of the Patient

Centered Medical Home (PCMH). New York State has more providers and practices with PCMH recognition

by the National Committee for Quality Assurance (NCQA) than any other state in the nation, and there have

been a number of PCMH pilots and initiatives designed to test and expand PCMH throughout the state.

To better understand the challenges and successes of becoming, sustaining and expanding the PCMH model,

interviews were conducted with the leadership of eight such initiatives. These included payer‐led and

provider‐led initiatives and government and technical assistance programs serving diverse populations in

both rural and urban areas:

Adirondack Medical Home Demonstration (AMHD)

Capital District Physicians Health Plan Medical Home Pilot (CDPHP)

Crystal Run Healthcare

Empire Blue Cross/Blue Shield (Empire)

Excellus and MVP Rochester Medical Home Initiative (Excellus was interviewed)

New York State Department of Health PCMH Medicaid Incentive Program (NYSDOH)

Primary Care Information Project (PCIP)

P2 Collaborative of Western New York (P2)

Interviews with PCMH initiative leadership covered four major issue areas:

Implementation:

Anticipated and unanticipated challenges, critical success factors, and the role of NCQA recognition in

the transformation process.

Payment:

Experiences and challenges with different ways of paying for care under PCMH.

Data and Measurement:

Challenges with data collection and analysis for PCMH, and the impact on PCMH implementation and

evidence.

Looking forward:

The sustainability of the PCMH model and how it has positioned organizations for other health reform

initiatives

The reports on these PCMH initiatives are not intended to be a comprehensive or scientific analysis, but an

identification of key issues as told by the leadership of the initiatives themselves. They are meant to be

illustrative and not generalizations about major trends. That said, their responses brought to light the

following themes and issues that could help inform PCMH adoption and expansion in New York State.

7 Overview

Evidence of improved clinical quality and access are emerging

All initiatives experienced improvements in clinical quality including increases in preventive screenings,

better access to care, and control of chronic conditions. Improved clinical processes, such as care

management and provider collaboration to ensure patients were receiving appropriate, evidence‐based

care at the right time, were often cited as reasons for the improvement in clinical quality scores. In

addition, PCMH payment incentives were cited as effective means of encouraging adoption of these

patient‐centered clinical processes. With these processes and incentives in place, the quality of care

provided seemed to improve.

For example, as the practices working with Excellus transformed into recognized medical homes, many of

them reached the 90th percentile in the region on nine clinical quality measures including hemoglobin A1C

less than 9 and less than 7, LDL less than 100, blood pressure less than 140/90, and increases in preventive

screenings like mammography and colonoscopy. Excellus attributes these improvements to key changes,

such as providing substantial PMPM incentives for patients with chronic diseases, aligning quality measures

with other health plan measures, embedding nurse care managers at practices, and encouraging

collaboration among disparate physicians.

Measurable health improvements often followed quality of care improvements. Crystal Run Healthcare was

able to bring the percentage of their patients with a hemoglobin A1C greater than 9 from 10 percent down

to 8 percent by encouraging collaboration between the primary care providers, endocrinologists, and care

managers. This team would review lists of these patients and identify actionable items to address with

each patient regarding his or her diabetic condition. This also decreased charges for diabetic care by 9

percent.

In general, the improvements in clinical quality metrics experienced by the pilots interviewed were similar

to those cited in recent analyses of other PCMH pilots.i Improvements in patients’ access to care and

adherence to treatment1 and costs savings from reductions in hospital use have been documented in some

PCMH evaluations.ii However, many pilots are still in the process of measuring the long‐term sustainability

of these improvements.iii

PCMH impact on long term cost savings as yet unclear Despite improvements in clinical quality, widespread adoption of PCMH will depend largely on the ability to

show cost savings or at least cost neutrality. While initial results were encouraging, there was still

uncertainty among most of the initiatives that measured cost savings about whether or not the savings

were associated with PCMH, particularly over the long term. Some initiatives said more time was needed

to demonstrate clear evidence of cost savings, or speculated that a weak economy (which occurred during

the course of the PCMH initiatives) contributed to lower utilization, could be distorting the impact of PCMH.

The findings were consistent with those in other states, which are still in the process of measuring the long‐

term sustainability of PCMH, particularly around cost.

On the road to pay‐for‐performance Few studies have documented the costs associated with becoming and sustaining a medical home. Most

agree that these expenses are significant, which may explain why large primary care practices are in a

8Overview

better position to transform than smaller practices and why a robust payment system covering all or most

of the practices’ patients may be needed to sustain PCMH.

Major PCMH costs cited by the initiatives included the up‐front costs of transformation, sustaining the

ancillary activities that are part of the PCMH model, and ensuring that payments are attached to a

percentage of patients that is large enough to motivate the practice to transform. In general, these PCMH

costs were covered either by payers contributing for their own members; by practices making the

investment mostly on their own with some additional PCMH monthly payments from payers; or by payers

covering PCMH practice costs even though the benefit extended beyond the payer’s own members.

Payer‐led PCMH initiatives interviewed used a variety of payment methodologies, including per‐member

per‐month (PMPM) incentive payments ranging from $2‐$24 in addition to standard fee‐for‐service (FFS) or

PMPM rates, risk‐adjusted capitated rates with differentials for case complexity, or enhanced FFS rates. For

many of these payment models, the level of payment corresponded to the level of NCQA PCMH

recognition.

Common challenges for the payer‐led initiatives included determining which payment methodology to use

and the magnitude of additional funds or enhanced payment rates that were needed to cover up‐front

costs of PCMH transformation to sustain the model while also incentivizing clinical quality. Addressing

these challenges often took some trial and error.

Most of the initiatives saw their current payment methodology as evolving toward a more precise pay‐for‐

performance methodology as a way to encourage quality improvement among practices and physicians.

However, for this methodology to become operational there needed to be more confidence and clarity in

the data.

Data challenges complicate progress Despite the large amount of data the healthcare system generates, interviewees all expressed concern with

availability, accuracy, validity, and completeness of data. Major challenges and barriers included pulling

and insuring accuracy of data from multiple sources; getting timely access to patient data from other

stakeholders such as hospitals and claims data from health plans; attributing activities and outcomes to

providers and practices appropriately, and connecting various data points to get an accurate picture of

access, quality of care, patient outcomes, and costs.

The interviewees found that these challenges were even more substantial in larger PCMH initiatives with

multiple payers, providers and EMRs. The Adirondack Medical Home Demonstration (AMHD), for instance,

has to manage data from seven different EMRs and multiple claims databases. Having multiple data

sources, disease indicators and risk stratification methodologies makes it difficult to prioritize who would

most benefit from care management services and creates uncertainty around whether the patients

receiving care management services are the ones who need it most. Moving forward, AMHD is seeking to

synthesize all of this information to make the data more actionable.

Data barriers can stall transformation and quality improvement efforts. For example, the lag time in

receiving claims data makes it difficult for physicians to make point of care decisions when delivering care.

9 Overview

With this time delay, physicians are left trying to understand the connection between what they did

months ago and the associated cost and quality outcomes they are currently experiencing.

As mentioned earlier, these barriers can make it difficult to move towards pay‐for‐performance models in

the PCMH setting. Excellus found that even within practices where all doctors are on the same EMR, there

are significant variations in documentation that lead to dramatic differences in reporting. Without

uniformity, Excellus may reward some doctors and “punish” others because of data idiosyncrasies rather

than actual quality variances.

In the short term, having actionable data to demonstrate quantitative and qualitative impact on costs and

patient health is critical to the sustained engagement of providers and payers in the PCMH enterprise. In

the long term, it is essential to building a reliable performance‐based payment system and risk‐sharing

Accountable Care Organization (ACO) models.

NCQA recognition: an element of transformation NCQA PCMH recognition was generally seen as providing an important framework for becoming a PCMH.

Official recognition was generally not viewed as the end goal but rather an important element of the

transformation process.

In comparison to the 2008 standards, the 2011 standards were viewed as much more rigorous and closer to

true “medical home,” and as a result, the problem of practices becoming recognized without transforming

has lessened. This is important, since most enhanced payments are still based primarily on PCMH

recognition level. Recognition‐based incentive payments were seen as an imperfect but necessary method

to incentivize quality and outcomes until more precise data‐driven performance‐based methodologies are

developed. This was the case for the NYSDOH project, which started by providing incentives to eligible

providers who reached any level of PCMH, but is now stopping incentives for PCMH Level 1. NYSDOH will

likely take other steps to incentivize more rigorous recognition and may require data reporting and meeting

performance standards.

Leadership and collaboration is critical Practice‐level leadership was seen as essential to success. Practices that were motivated, engaged in the

tenets of the medical home, and brought their teams along on the journey were most likely to succeed.

When they saw the results of their efforts, it motivated them to progress more. Practices with physicians

who were not capable of transforming themselves, let alone bringing their staff along, threatened to slow

down or complicate the initiative. There was a general realization that, while outside technical assistance

might support initial improvements, practices had to be capable of and willing to embrace change to

achieve long‐term results. The challenge for those implementing broad PCMH initiatives was to focus on

those who had the capability and determination to move forward.

For example, the P2 Collaborative of Western New York found that “pockets of resistance” could slow down

PCMH transformation. They had several cases where the physician leading the practice was the biggest

barrier to change, even if the staff was eager to move forward. This can be a challenge for technical

assistance providers as well. Faced with similar resistance, PCIP had to stratify the practices it served,

engaging those who were most committed to succeed, while postponing others who were not yet willing or

able to commit the necessary resources.

10Overview

For those operating PCMH initiatives across practices (and/or payers), collaboration was key. There had to

be recognition that while the stakeholders may be competitors on some level, PCMH was in their collective

best interest of all involved. For example, AMHD anticipated buy‐in resistance from its stakeholders,

particularly payers. To address this, AMHD’s governance structure played an essential role, and has made

all decisions by consensus. Collaboration was also viewed as a primary factor for AMHD, CDPHP, Excellus

and P2 being selected to participate in large multi‐stakeholder initiatives.

PCMH training needed at all levels Practically all of the initiatives cited the need for more personnel at all levels to be trained and attuned to

the tenets of PCMH – from the front desk staff to care managers to the clinicians. Training, recruiting and

retaining individuals with critical thinking, collaboration and team skills was seen as necessary for sustaining

the PCMH model.

The need for more care management training was specifically identified by several initiatives as they go

about expanding their PCMH efforts. For example, Crystal Run expressed difficulty recruiting nurses with a

care management background and suggested a care manager training role for clinical institutions.

Building on the PCMH foundation Regardless of the challenges, the process of transforming, collaborating and risk‐taking prepared all of the

initiatives for the next stage in a fast‐evolving healthcare environment. Whether going from demonstration

to widespread adoption, or participating in a broader multi‐stakeholder effort, each initiative made enough

progress to take the next step on the healthcare transformation journey.

The Adirondack Medical Home Demonstration is providing the infrastructure for Health Homes –

the NYS Department of Health initiative to coordinate care for the highest need/highest cost

Medicaid patients.

CDPHP is engaged in the CMMI Comprehensive Primary Care Initiative – a federally‐sponsored

multi‐payer collaborative (including Medicare) throughout the Capital region and Hudson Valley.

Crystal Run Healthcare is expanding from a medical neighborhood that includes specialists into an

ACO that will allow it to share savings with Medicare and will position the practice to manage care

and costs for ever larger groups of patients.

Empire Blue Cross/Blue Shield is moving from a demonstration to launching its Patient‐Centered

Primary Care program – a new insurance initiative to provide incentives for transformation and to

reach quality, cost & utilization goals.

Excellus and MVP will participate in “Transforming Primary Care Delivery: A Community

Partnership,” a $26.5 million CMMI Innovation program to expand their PCMH model to hundreds

more primary care providers in the Rochester/Finger Lakes region.

New York State Department of Health is expanding and refining its Medicaid PCMH initiatives,

including incentivizing hospital outpatient and residency programs to adopt medical homes,

ratcheting up levels of medical home‐ness that will receive incentive payments from the Medicaid

program, and integrating PCMH into multiple initiatives in New York’s Medicaid Redesign Waiver.

11 Overview

Primary Care Information Project is leveraging electronic health records and PCMH to improve the

quality of primary care, and to encourage greater awareness to stay healthy among New York City

residents.

P2 Collaborative is integrating the medical home model into a new regional planning initiative for

Western New York.

These eight diverse pioneers are pushing ahead with a more advanced model of care delivery. Their

successes and struggles will be important to understand as the healthcare market shifts to emphasize

quality of care over quantity, and as New York moves forward with initiatives that put our healthcare

system on a more sustainable path.

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TheAdirondackMedicalHomeDemonstration(AMHD)www.adkmedicalhome.org

Overview

Goals: Improve quality & outcomes, lower overall health care costs, improve access; create a clinically

integrated model; improve provider satisfaction/retention (increase capacity)

Summary: AMHD is one of the nation’s first multi‐payer PCMH pilots. It is a provider‐initiated effort that

has brought together all of the payers in the region, including Medicaid and Medicare. Payers have

committed to support the cost of developing and sustaining the PCMH model over the course of the

initiative. Special state legislation was enacted to allow payers limited anti‐trust immunity so they could

collaborate. The project is divided into three “Pods”: Tri‐Lakes (Adirondack Health Institute), Lake George

(Hudson Headwaters Healthcare Network), and Adirondack (CVPH Medical Center). New York State

participates by supervising discussions with respect to anti‐trust immunity Medicaid participation, applying

for federal/CMS participation through the Multi‐Payer Advanced Primary Care Practice Demonstration

(MAPCP), and convening stakeholders.

Providers have to obtain NCQA PCMH recognition at Level 2 or 3 in order to receive the $7 PMPM incentive

payments. In addition to NCQA recognition, providers are expected to meet a series of performance

benchmarks focused on access, continuity, clinical care, patient satisfaction, utilization, and costs. AMHD

focuses on six chronic diseases prevalent in the region: diabetes, hypertension, coronary artery disease,

pediatric asthma, obesity, as well as prevention (i.e. lead screenings, immunizations). The project has five

years to demonstrate that it can address the primary care crisis in the Adirondack region.

Timeframe: Five‐year initiative started in 2009.

Location: Adirondack Mountain Region: Clinton, Essex, Franklin and Hamilton counties, plus affiliated

physicians in 7 surrounding counties.)

Size today: Participation includes more than 40 practices representing 120 physicians and 96 physician

assistants and nurse practitioners, five hospitals, seven commercial health plans, Medicaid, Medicare, the

New York State Department of Health, the Medical Society of the State of New York, and the New York

State Association of Counties.

Interviewees: Cathy Homkey, Adirondack Health Institute, Inc. CEO; Cynthia Nassivera‐Reynolds, Hudson

Headwaters Health Network, VP Medical Home Support; Bob Cawley, Adirondack Health Institute, Director

of Medical Home Initiatives

________

Implementation: Collaborative decision‐making to overcome skepticism

For AMHD, the PCMH recognition process was a first step in building a greater collective understanding of

the PCMH model for payers and providers alike. The recognition process was helpful in establishing a

benchmark for all providers to achieve (all but one of 40 practices achieved Level 3 PCMH). It was also the

TheAdirondackMedicalHomeDemonstration

13

The PCMH process has

empowered patients

first time most practices had looked at their data in a way that could help them improve their performance,

establishing a significant first step as they moved forward through the transformation process.

AMHD anticipated buy‐in resistance from its stakeholders, particularly payers. While there is an inherent

tension between payers and providers, and a lack of evidence demonstrating whether the program reduces

costs, the payers have largely remained on board and supportive. AMHD attributes much of the success

with collaboration to the governance structure, which included a governance committee, subcommittees,

Adirondack Health Institute governance, and governance for each Pod. The NYS Department of Health

played a crucial role in “setting the table” for successful collaboration to occur, and all decisions have been

made by consensus.

From the provider’s perspective, this process has helped to build

a stronger collaborative relationship with patients. Before the

pilot, patients were passive recipients of healthcare. Their

doctors would tell them what to do and they would leave. They

weren’t involved in the process. Now AMHD is helping to

empower patients. There is evidence of more two‐way doctor‐

patient communication, greater patient satisfaction, and better health outcomes. AMHD also cited the

need for more staff (doctors, nurses and support staff) that are ready to work in a medical home

environment and can work collaboratively with patients.

Measurement: A need to synthesize from multiple data sources

The largest data challenge AMHD faces is data overload. AMHD uses Treo Solutions, a data aggregator, to

take claims data from each of the payers and stratify each patient in a risk category ranging from healthy to

multiple chronic conditions. It can also report on patients who jump between categories – those whose

health has improved or those who are starting to develop health issues. This helps AMHD identify patients

in need of care management. Treo also gives gap reports, showing patients who were discharged from the

hospital without follow up, or visits where no A1C test was administered, etc.

CMS, as a member of the initiative, also brought in predicative modeling software that risk stratifies

AMHD’s patients and provides quarterly reports identifying the practices’ very high risk patients. The

practices run their own reports from their EHR systems, looking at diabetic patients. And now, the NYS

Medicaid Health Home program is conducting its own risk stratification.

There are seven different EHR systems involved in the project. The clinical quality data vendor,

Massachusetts eHealth Collaborative (MAeHC), has been working to reconcile the data in these systems, to

create a Quality reporting database, called the Quality Data Center (QDC). However, they have not yet

attempted to reconcile with the Treo claims database.

The multiple data sources, disease indicators and risk stratification methodologies often provide conflicting

information, making it challenging to determine who would most benefit from care management services.

AMHD care managers engage patients and show improved outcomes, but they are uncertain if the patients

receiving care management services are the ones who need it most, or if there are others whose care

management needs are being unmet. Moving forward, AMHD is seeking to synthesize all of this

information to make the data more actionable.


14

Payment: From Process to Performance Pay

While the $7 PMPM is expected to cover the cost of care management, it is unclear whether the payment is

sufficient to cover the costs to the practices associated with sustaining “medical home‐ness.” AMHD had

always envisioned a component of payment would be performance based, and is taking initial steps to

move providers from payment for process to payment based on specific outcomes. AMHD anticipates that

practices will be measured based on quality, utilization, and patient experience.

The premise is that having some of their payment based on achieving certain quality and cost goals, with

enhanced payments for those with superior results, will encourage more physicians to deliver high quality,

lower cost health care, and lead to more successful recruitment and retention of physicians in the region.

Moving Forward: Challenges ahead but many promising opportunities

With data access and coordination a major issue, AMHD leadership recommends public policy changes to

allow greater sharing of data between accountable entities while maintaining patient privacy. Also, AMHD

cites a major need not just for primary care doctors in its rural communities, but a new class of care

managers, care navigators and other staff to carry out PCMH care coordination and care management

activities. Training programs are needed to ensure a pipeline of staff that can work effectively in the PCMH.

This initiative has positioned the Adirondack Health Institute to provide AMHD program oversight and to

build the infrastructure needed to administer and participate in several other initiatives moving forward,

such as Health Homes (a major care coordination initiative targeting the highest cost Medicaid patients

with multiple chronic conditions), grant‐funded data analysis, and a CMS initiative with the NYS

Department of Health.


15

Capital District Physicians’ Health Plan (CDPHP) Enhanced Primary Care Initiative www.cdphp.com Overview Goals: To test the hypothesis that the aggregate savings associated with better health outcomes and lower

utilization would be sufficient to fund enhanced compensation to primary care physicians.

Summary: CDPHP is a major health plan covering the capital district and mid‐Hudson valley. In May 2008,

CDPHP launched a medical home pilot with three practices with 15 physicians that had between 40‐50

percent CDPHP enrollees, an EHR, and strong peer leadership potential. The new payment model was

launched with practices in 2009 and 2010. Based on initial quality and efficiency improvements, and later

evidence of aggregate savings, the initiative was expanded significantly in each subsequent year.

The CDPHP payment model is a risk adjusted base capitation and bonus program, based on IHI Triple Aim.

The bonus is aimed at rewarding practices that are successful in maintaining patient satisfaction (CG

CAHPS+ PCMH specific survey questions); effectiveness and quality (HEDIS measures); and efficiency and

utilization (hospital and ED rates, population‐based efficiency metrics).

Current indicators of success include $8 PMPM savings (compared to other area physician practices); 15

percent reduction in inpatient admissions; 9 percent reduction in emergency department utilization; and 7

percent reduction in high‐tech imaging.

Timeframe: Practice Reform Initiative begun in 2008 and Payment Reform Initiative begun in 2009.

Participation has expanded each year.

Location: Albany Region, Counties: Albany, Broome, Columbia, Dutchess, Fulton, Greene, Montgomery,

Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren and Washington

Size today: 161 practices and over 700 clinicians covering over 180,000 lives.

Interviewee: Lisa Sasko, Director of Clinical Transformation, CDPHP

________

Implementation: NCQA a “first step,” but physician leadership key to success

NCQA recognition has served as a strong first step in PCMH transformation for CDPHP. While the NCQA

recognition process may entail “checking boxes,” the elements embodied in recognition build a

transformation program that demonstrates the principles of medical home and that integrate well with EHR

Meaningful Use. The NCQA PCMH recognition process served as a good framework to build transformation

for CDPHP’s initiatives and the process supported integrating PCMH principles into CDPHP’s practices.

From the beginning of the initiative, CDPHP found physician leadership to be critical to success. With so

much change, CDPHP found that staff had to look up to a leader in the practice as a champion for the

CapitalDistrictPhysicians’HealthPlan

16

CDPHP’s risk‐adjusted capitation

model produced $8 PMPM

in savings

cause. Practices that face the greatest challenges were those without sufficient physician leadership, and

this hampered implementation at the start of the initiative. As the pilot progressed, CDPHP determined

that specific components of their transition curriculum needed to be devoted to developing physician

leadership.

Measurement: Addressing data delays

CDPHP collects and analyzes the claims data it receives from practices, looking primarily at patient

experience, quality of care, costs and utilization to ensure rates are set appropriately to create a

sustainable PCMH model that will realize long term gains. This is particularly to ensure that costs are

adequately covered as CDPHP transitions providers from fee‐for‐service to risk‐adjusted capitation.

CDPHP shares data with practices on a quarterly basis, but the data is delayed by about five months. As

CDPHP progressed through its initiative, this delay hampered practices’ ability to determine if their actions

affected cost or quality. CDPHP worked with a market vendor, Verisk, to develop “Medical Intelligence”, a

self‐serve tool that allows practices to see claims data within 30 days of the claim being processed. This

enabled doctors to see more timely information on emergency visits, inpatient hospitalizations, specialty

referrals and pharmacy usage.

Payment: Challenges of creating a new model

Initially, one of the major goals CDPHP’s payment reform model

was to determine if strong incentives could change the behavior

of providers to encourage full PCMH adoption. From 2009 to

2011, CDPHP worked with three practices to create a virtual all‐

payer scenario, using a capitation model that added

approximately $85,000 more per PCMH physician, regardless of

how many CDPHP members were in the physician’s panel. Results from that initial pilot determined that

the model provided an $8/pmpm savings pilot‐wide.

From there, CDPHP created a network‐wide model to help make PCMH transformation more sustainable

for more providers. Currently, the CDPHP Enhanced Primary Care Initiative supports initial investment in

transformation by providing practices with a $20,000 stipend to become NCQA recognized and begin initial

steps towards full transformation. Once NCQA Level 3 is achieved, providers are eligible for a 20 percent

increase in payments over the base pay, as well as the 20 percent bonus incentive, giving each provider the

possibility of a 40 percent payment increase. Currently, about 70 percent of CDPHPs’ adult medicine

payments are under the risk‐adjusted capitation model. Some claims are still paid through fee for service

to incentivize utilization, as are all drugs and vaccinations.

To achieve the risk‐adjusted capitation model, CDPHP developed a new structure and model for processing

claims. CDPHP faced substantial challenges in the development and contracting of claims processing within

this new risk adjusted capitation model. CDPHP is putting in significant effort and follow up to make sure

all of the coding and processes are being input correctly and paid out properly.


17

Moving Forward: “Letting the cake bake,” and forging new partnerships

CDPHP has invested more than $15 million in the past four years to start the pilot and develop the risk‐

adjusted PCMH model. CDPHP was initially skeptical and concern that no other payers were following their

example. After an ambitious startup year, and only 2 years into the program, CDPHP has seen promising

results, but says it is still too early to tell if the program will be a long‐term success. Payers and providers

alike have to be patient and “let the cake bake.”

But the model is being taken seriously. This year, CDPHP was selected as one of the payers in the federal

CMMI Comprehensive Primary Care Initiative (CPCI) for the Capital District‐Hudson Valley region – a multi‐

payer initiative fostering collaboration between public and private payers to strengthen primary care in the

region. CPCI promises new resources and an environment that will allow CDPHP to test its model in a multi‐

payer environment and a broader region.

CPCI will bring new challenges as well. CDPHP will need to collaborate with other payers, and while CDPHP

has always shared its methods, sharing is not a natural instinct for payers. However, there is optimism in

the project, and a growing recognition that the model can be successful if everyone works collaboratively

towards shared goals.


18

Crystal Run Healthcare www.crystalrunhealthcare.com

Overview:

Goals: To create high functioning teams and a medical home environment that incorporates all personnel.

Summary: Crystal Run Healthcare is a 15‐site multispecialty practice. Six of Crystal Run’s primary care sites

and five specialty sites are organized as “medical neighborhoods.” The specialties include endocrinology,

neurology, oncology, pain management, orthopedics and most recently, allergy/ENT. Within these medical

neighborhoods, Crystal Run applies the NCQA PCMH framework and principles, including embedded care

managers and monthly meetings to review workflow, share quality measures, and use “interesting cases”

to reinforce what is working well and explore areas that need improvement.

Crystal Run adapted and optimized its PCMH activities over time. Although they have used patient care

managers for nine years, Crystal Run has recently embedded care managers in the medical neighborhoods,

not just in their primary care practices. Care managers focus primarily on coordinating care for high‐risk

patients and leverage outside resources and community support for patients if needed. Crystal Run also

has a quality assurance team that tracks patient safety and quality improvement measures, and a database

analysis/business intelligence team to measure and report on care and costs. Crystal Run is now developing

CARETEAM (Community and Residential Extenders for Transitions, Evaluation and Management) – a

program to help prevent unnecessary hospital readmissions.

All of Crystal Run’s primary care practice sites are NCQA recognized Level 3 PCMHs, and Crystal Run is

recognized as one of six “Early Adopters” in the nation seeking NCQA ACO accreditation. Quality

improvement and outcomes data is shared monthly at medical neighborhood meetings, with reports at the

physician, practice and neighborhood level. Hypertension, diabetes, coronary artery disease, and chronic

obstructive pulmonary disease are among the clinically important conditions that Crystal Run tracks.

Timeframe: Initiative started in 2004 with the introduction of care managers and is on‐going.

Location: Orange and Sullivan Counties (mid‐Hudson Valley and lower Catskill region)

Size today: 250 multi‐specialty physician group; 300 plus providers, 15 sites

Interviewees: Hal Teitelbaum, MD, CEO; Gregory Spencer, MD, Chief Medical Officer; Scott Hines, MD, Co‐

Chief Clinical Transformation Officer; Jon Nasser, MD, Co‐Chief Clinical Transformation Officer; Betty

Jessup, Director of Quality and Patient Safety

________

Implementation: Care management staffing, non‐Crystal Run provider cooperation proves challenging

One of the keys to building high‐functioning teams has been Crystal Run’s ability to recruit and retain staff

that are interested and engaged in the tenets of the medical home. Nevertheless, that recruitment can

prove to be challenging. Crystal Run is still hiring and building its care management team but has had

difficulty recruiting care managers. Finding nurses with case management backgrounds and experience

CrystalRunHealthcare

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While EHR data is useful, without

claims data they cannot see what

care and services the patient

receives outside Crystal Run

with critical thinking and panel assessment skills has been a particular challenge. Crystal Run suggests the

need for care manager training curriculum at clinical institutions.

Another challenge has been the lack of acceptance of the PCMH model by non‐Crystal Run providers.

Generally, local hospitals are not actively coordinating care with or providing data to Crystal Run, even

though the practice is a major hospital admitter. To work around the resistance, Crystal Run pays for and

places transitional care managers in its primary hospital, which has resulted in decreased readmissions

and length of stay. Crystal Run Healthcare has also engaged one of the regional tertiary centers to improve

the transition back to Crystal Run’s medical home after discharge from that institution.

Measurement: Promising results, but claims data would prevent “leakage”

Crystal Run is demonstrating that access to care correlates to better care. For example, discovering that a

major impediment to blood pressure follow‐ups was the cost to the patient, Crystal Run established a

hypertension protocol that includes no‐cost blood pressure checks. Crystal Run has also engaged its

physicians in reducing practice variation that targets common diagnoses in each specialty, resulting in

reduced patient charges in nine other practice areas. Despite lowering practice revenue per patient in the

current fee for service environment, Crystal Run is committed to value based care and believes that “giving

something away in the short term” will have long term benefits not only for its patients but for the practice

as well.

The most significant challenge for Crystal Run has been its

inability to access claims level data. (Dr. Teitelbaum suggests

payers be required to share claims data with practices in real time

‐ or close to it). While their EHR data is useful, without claims

data they cannot see what care and services the patient receives

outside Crystal Run (“leakage”). Knowing where patients are

going for care and what procedures they are having would help

Crystal Run’s doctors spot problems earlier, coordinate care

better, and factor cost into patient’s care plans. On those occasions when data is provided by different

payers, it is often provided in different non‐standard formats, frequently contains significant inaccuracies

(i.e. misclassification of providers by specialty, attribution of providers to the wrong medical practice) and

lacks transparency and verifiability.

Payment: A vision for population/performance‐based payment

The PCMH incentive payments from payers add up to less than half a percent of total revenue, most of

which has come through Medicaid and THINC (Taconic Health Information Network and Community), in

which Crystal Run participates.

While Crystal Run is pleased to have these additional resources, they do not come close to supporting

Crystal Run’s medical home infrastructure. Dr. Teitelbaum figures a physician with a 2,500 to 3,000 patient

panel requires $150,000 to cover all medical home‐related services. That includes a full‐time care manager,

EHR, analytics, appropriate support, and additional compensation for the physician, who is now managing

his patients’ care across the healthcare system.


20

Continuous engagement of

physicians, nurses and staff helps

them go where they need to go

By making the investment itself, Crystal Run has not had to negotiate with payers that may have their own

proprietary medical home initiatives and disparate care management functions that cover only their

portions of their patients. The downside has been the inability to obtain claims data.

Crystal Run considers PCMH part of the evolutionary process of moving from a transaction‐based universe

to an entirely population‐based payment system where payment is calibrated with providing best possible

care to patients, preferably at lowest possible cost. Crystal Run envisions that three years from now, it will

earn revenues based almost entirely on a combination of population under care and the quality of the

outcomes they achieve for their patients.

Moving Forward: From PCMH to ACO

Crystal Run’s practice model and payment vision likely played a

role in their becoming CMS Pioneer ACO finalist and participant in

its Medicare Shared Savings Program ACO – one of six CMS‐

approved ACOs in New York State. Crystal Run says the medical

home is foundational to an ACO, because it focuses on improving

the quality of care and the efficiency with which care is delivered.

With the ACO designation, Crystal Run is looking even more carefully at readmissions, the ratio of specialist

follow up visits per consultation, and other utilization indicators. They are encouraging their PCMH primary

care physicians to work to the top of their license and watching specialist use carefully. They are comparing

and contrasting their six primary care medical neighborhoods to determine where they are getting more

cost effective results, and more importantly, why they are getting these results.

In 2006, Crystal Run was the first medical practice in New York State to become fully accredited by the Joint

Commission. As of today, Crystal Run has established medical homes, grown them into medical

neighborhoods, is fast evolving into an accountable care organization (ACO), and is the largest for‐profit

employer in Orange and Sullivan Counties. Each step they have taken has led to the next, and continuous

engagement of physicians, nurses and staff helps them go where they need to go.


21

Empire Blue Cross/Blue Shield Medical Home Demonstration www.empireblue.com

Overview:

Goals: To demonstrate whether PCPs that achieved PCMH recognition had improved quality and a lower

total cost of care.

Summary: Empire Blue Cross/Blue Shield, a WellPoint company serving New York’s downstate region, was

involved in three medical home projects in New York State ‐ the Adirondack Medical Home Project, the

THINC Mid‐Hudson Valley Medical Home project, and their own downstate project.

This profile focuses on the downstate project. Empire was primarily trying to demonstrate whether PCPs

that achieved PCMH recognition had improved quality and a lower total cost of care. Empire measured

quality through HEDIS metrics and demonstrated cost savings through lower emergency room visit rates,

reduction of preventable re‐admissions, and prescription of generic drugs vs. brand‐name drugs.

Empire will end the demonstration and migrate it to an on‐going Patient Centered Primary Care program

effective January 2013. The new program will use a shared savings model for maintained or improved

quality and reduced costs. Empire will provide extra payments during the PCMH transformation process to

support the upfront costs of PCMH adoption and transformation. After implementation, the extra

payments will be used as quality incentives. The new system will use WellPoint's personal health record

system (MMHPlus) to support data exchange with medical homes, which provides PCMHs with patient

claims history and clinical information.

Timeframe: Empire’s PCMH demonstration began in 2010 and will transition into an on‐going Patient

Centered Primary Care program effective January 2013.

Location: Downstate region (New York City, Nassau, Suffolk and Westchester Counties).

Size today: Started with 10 practice groups, 86 locations, 250 physicians, 34,000 patients, all of which were

in Empire’s own network of providers. Will expand in January 2013 through Patient‐Centered Primary Care

program.

Interviewees: John Caby, Vice President, Provider Engagement & Contracting – NY; Scott Breidbart, MD,

Medical Director; and Philip Thomas, Program Manager

________

Measurement: Promising results on cost and quality

A recent study published in the American Journal of Managed Care looked at 2008 data from PCMH and

non‐PCMH practices in Empire’s network, and found significant clinical outcome and cost differences. The

study compared a cohort of Empire patients (31,032) in PCMH practices and a larger number (350,015) that

were not. Results showed risk‐adjusted, measurable improvements for patients in PCMH practices,

including:

Diabetics receiving A1C testing: 82.1 percent for PCMH/77.7 percent for non‐PCMH patients

Children administered antibiotics: 27.5 percent for PCMH/35.4 percent for non‐PCMH patients

Hospitalizations (age 45‐64): 8.1 percent for PCMH/9.4 percent for non‐PCMH patients

EmpireBlueCross/BlueShield

22

While Empire will require providers

to become recognized over time,

they believe the cost and quality

gains can be realized long before

Mean adult PMPM medical costs (incl. pharmacy): $481 for PCMH/$584 for non‐PCMH patientsiv

While the study compared PCMH to non‐PCMH outcomes, the data was from 2008 – before most of the

practices received NCQA PCMH recognition, and before Empire (or anyone else) introduced incentive

payments and care coordination services. This appears to demonstrate that many providers have been

practicing as medical homes before seeking NCQA recognition – and achieving results. For these practices

and this set of results at least, the recognition and incentives had no bearing on quality and cost. Those

were already inherent in the practice, or surfaced as part of the transformation process.

Payment: Coordinating physician support and critical mass

Through the demonstration, Empire engaged physicians and practices in its network and began paying a

care management fee to its providers of about $3 per patient per month for PCMH Level 1, $5 for Level 2

and $7 for Level 3. Practices varied from small independent group practices, practices affiliated with

academic medical centers, and federally qualified health centers.

One of the key challenges was determining the right level of payment. With this pilot program, Empire

wanted to ensure they were covering the cost of transformation, allowing practices to bring on a care

coordinator, and that physicians felt supported in their PCMH activities. Since Empire was the only payer

besides the NYS Medicaid Incentive program, other payers were unavailable to help cover the costs of care

management services.

Moving Forward: Do you have to be a Medical Home to be a medical home?

WellPoint (Empire BlueCross BlueShield in New York) is now rolling out their new Patient‐Centered Primary

Care program. In this new initiative, practices do not have to be recognized PCMH practices – at least in the

beginning. While Empire recognizes the correlation between a

recognized practice and the quality and cost measures, they

believe they can achieve cost and quality gains long before

recognition. Further, Empires says there are not enough

recognized practices to form the network they hope to develop

that meets network adequacy requirements. Ultimately, Empire

needs more primary care physicians ready and able to practice

through a patient‐centered approach – whether the practice is

NCQA‐recognized or not.

Empire is building their network around an “enterprise strategy.” They are looking at the challenges of

becoming a medical home (initial investment, transformation, care management, adoption of more

advanced health information technology, etc.) and the physician’s concern about whether they will be

compensated enough to sustain the practice as a medical home. They are providing incentives in the form

of a care management fee (PMPM) for non‐PCMH recognized practices, and payments that will help

providers generate more revenue as result of quality and efficiency outcomes and metrics. Empire says the

initiative will make it possible for providers to earn 20‐30 percent more if they achieve these outcomes.

Empire is working to address challenges in this new initiative that were identified in the pilot. The pilot

project highlighted the need for care management support for providers with smaller patient panels. The

new Patient Centered Primary Care program will go further to support physicians with analytics and


23

integration with Empire’s own care management team where needed. Additionally, self‐insured employers

with Administrative Services Only (ASO) contracts may prefer to “draw [cost and quality] correlation

directly to their own members, as opposed to Empire’s entire patient population.” Increasing fee for

service reimbursement may be easier to justify to the ASO customer than sharing a portion of the savings

that result from the Patient Centered Primary Care initiative.

Empire is confident that it can build a sustainable Patient Centered Primary Care initiative that will

encourage more primary care providers to transform their practices, and attract more physicians into the

primary care field.


24

Excellus and MVP Rochester Medical Home Initiative www.excellusbcbs.com

Overview

Goals: To catalyze more primary care providers to adopt PCMH and evaluate the impact of PCMH on a

physician’s patients.

Summary: Excellus and MVP insure a large percentage of the population in the Rochester area, with

Excellus covering about 40‐50 percent of the market, and MVP about 20 percent. The two plans developed

a medical home demonstration with seven practices covering 33,000 patients. Excellus and MVP chose to

coordinate on quality measures, but because of anti‐trust concerns, they did not coordinate on payment

methodologies. This profile focuses on the experience of Excellus.

One of the major purposes of the pilot was to evaluate the impact of the PCMH program on all patients, not

just Excellus and MVP’s subscribers. To achieve this, the pilot was relatively small, and Excellus covered the

costs not only of its own members but the practices’ uninsured, Medicaid and Medicare patients.

As part of the pilot, providers were required to have a minimum of one nurse care manager for every four

physicians; have a connection to MD Datacorp (which analyzed and aggregated EHR and claims data);

participate in a learning collaborative; and achieve and maintain NCQA Level 3 PCMH recognition. The

health plan built a cadre of nurse “transformation” consultants who helped identify challenge areas and

opportunities and helped the practices stay on track as they continued to transform.

As a result of the pilot, quality of care improved across a series of indicators, outcomes have improved year

after year since 2009, and patients score about 20 percent better on health indicators than the rest of

Rochester community. This included reducing LDL cholesterol to optimal levels of less than 100 for 75

percent of heart disease patients and 70 percent of diabetics; increasing colorectal and breast cancer

screening rates from 60 to 75 percent; and lowering blood pressure levels to below 140/90 for 80 percent

of hypertension patients.

Timeframe: Initiative started in 2009. Model now included in three‐year CMMI project.

Location: Monroe County (Rochester)

Size today: Same as original: seven practices with 33,000 patients, but over 150 providers have become

NCQA Level 3 recognized since the initiative began

Interviewees: Martin Lustick, MD, Senior Vice President and Corporate Medical Director, Excellus Blue

Cross/Blue Shield

________

Implementation: Recognition is important, but leadership and collaboration are essential

The NCQA recognition process has been a useful tool in PCMH implementation and transformation but not

an end in itself. Excellus understood that there was a risk that practices could become PCMH recognized

and not substantively change the way they do business. To help mitigate this risk, Excellus staff used

ExcellusBlueCross/BlueShield

25

The PCMH movement has caught

on in Rochester

satisfaction surveys, performance measures, and quality improvement projects, along with on‐site

collaboration and observation to ensure that the practices were truly transforming.

Excellus found that successful PCMH transformation requires significant leadership within the practices.

While the pilot had a rigorous application process that screened for the most progressive practices, that did

not necessarily translate into leadership skills. Excellus provided significant support to some of the

practices only to find, three years later, that they are still not making the progress they would like.

But the PCMH movement has caught on in Rochester. Three

years after it started, about 150 additional primary care

providers in the Rochester region have achieved Level 3 NCQA

accreditation – validating Excellus’ goal of catalyzing more

primary care providers to adopt PCMH. The pilot has also

strengthened communication and coordination efforts

throughout the Rochester health care delivery system.

The initiative’s coordination among plans, payers and physicians has also been rewarding. With significant

variation in patient demographics and in practice style, practices were still able to come together and

achieve significant results. PCMH growth can also be attributed to encouragement from Rochester’s

business community. The Rochester Business Alliance, a strong voice in Rochester, engaged early in the

process and communicated the value of the medical home throughout the business community. It shows

that working together can achieve results.

Measurement: Getting timely claims and reliable EHR data

Excellus is only able to provide practices with utilization data on a monthly or quarterly basis, and financial

data on an annual basis. Doctors have complained that the claims utilization data should be available more

frequently, so that they can know immediately when their patients go to the emergency room (not a month

after, or even later). To address this issue, Excellus is working with the practices, specialists, hospitals, and

local RHIO (regional health information organization) to get more timely information, but it is a constant

struggle.

The ability to extract reliable and valid clinical data from EHRs presents another challenge, as it requires

significant manual maintenance. Because Excellus is basing payment on clinical quality metrics, this

information has to be fairly accurate. Even within practices that use the same EHR, significant variations in

the way doctors document leads to dramatic differences in reporting. Without uniformity, Excellus may

inadvertently reward some doctors and “punish” others based on idiosyncrasies rather than actual quality

variances.

To help counter this, the pilot requires all practices to connect to MD Datacorp, which pulls monthly data

from EHRs to create a population database, and helps to ensure that performance indicators are all being

measured uniformly across practices with different EHRs and different processes.

Payment: Targeting the most complex patients

Rather than offering a PMPM for all patients, Excellus made relatively robust payments ($24 PMPM) for

patients with chronic diseases. The payments were intended to cover appropriate care coordination and

ExcellusBlueCross/BlueShield

26

PCMH services for all patients who needed them, but by targeting the most complex patients, they were

able to mitigate issues of cherry picking healthy patients. The fee is adjusted annually based on

performance. Increased payments not only covered the costs of transformation and operating as a medical

home, they also boosted doctors’ take home pay significantly – possibly by 40 percent. Excellus realized

that this kind of robust payment structure covering all of the provider’s PCMH costs was appropriate for a

relatively small scale demonstration, but in the long run, other payers would need to contribute to make

the model sustainable.

Moving Forward: Uncertainty about sustainability, but new initiative will build evidence and confidence

While PCMH pilots around the country have demonstrated significant savingsv (with their own pilot

showing similar results), Excellus does not consider the evidence strong enough to adopt the model on a

widespread basis to control cost and utilization. While evidence suggested that the PCMH project could

have contributed to cost and utilization reductions, that evidence cannot be separated from the impact of a

weak economy. With a fair amount of conflicting data, Excellus is not convinced about the long term

financial sustainability of PCMH.

The uncertainty affects buy‐in from employers and Excellus’ subscribers. Excellus engaged its own business

clients, showing them the additional costs (relatively minor compared to overall premiums) and what they

hoped would be the long‐term value. There was no significant resistance, but as the program expands,

employer buy‐in will become a more prevalent issue.

Excellus has a few more years to test the model. The health plan is part of a three year, $26.5 million CMMI

Grant titled “Transforming Primary Care Delivery: A Community Partnership,” awarded to the Finger Lakes

Health Systems Agency. The project seeks to expand the pilot to cover virtually all primary care providers in

the greater Rochester/Finger Lakes region. It is expected to train 726 health care workers and hire 76

workers in positions as care managers, community health workers, community‐based care coordinators,

and practice improvement advisors. It involves multiple stakeholders, including the planning agency, the

two large health plans, physician groups, all three Rochester health systems, business and community

leaders, and the NYS Department of Health.

Excellus is hoping the project will create a sustainable medical home infrastructure for the region – and for

their network.

27

New York State Department of Health PCMH Medicaid Incentive Program www.health.ny.gov

Overview:

Goals: To improve access to high quality primary care through broad PCMH adoption by primary care

providers and practices serving New York State’s Medicaid population.

Summary: In an effort to improve and ensure greater quality and effectiveness of primary care practices

participating in Medicaid, the New York State Department of Health (NYSDOH) developed the Statewide

Patient‐Centered Medical Home Incentive Program. The initial goal of the Medicaid PCMH program,

initiated in 2010, was to generate broad PCMH adoption by primary care providers and practices – to try to

ensure that while they ‘raised the bar’ with respect to primary care standards, they were not so high that

few practices could participate in the process of transformation.

The program is available to all New York State office‐based primary care practitioners, as well as state

licensed diagnostic and treatment centers, hospital outpatient departments, and federally qualified health

centers (Article 28 facilities). Providers must be NCQA recognized at levels 1, 2 or 3 under PCMH 2008 or

2011 standards and are paid either a PMPM as a direct pass through from Medicaid managed care plans, or

a fee for service (FFS) incentive added to selected evaluation and management codes calculated to achieve

on average the same PMPM reimbursement.

PCMH Level 1: $2 PMPM / $5.50 Article 28 FFS / $7 office‐based FFS

PCMH Level 2: $4 PMPM / $11.25 Article 28 FFS / $14.25 office‐based FFS

PCMH Level 3: $6 PMPM / $16.75 Article 28 FFS / $21.25 office‐based FFS

With more than 5,000 recognized PCMH providers and multiple PCMH pilots, New York now has far more

medical home activity than any other state. New York State’s PCMH Medicaid incentive program is widely

viewed as a primary reason for the rapid and robust adoption of PCMH in New York State, particularly in

New York City and other urban areas with large concentrations of Medicaid recipients.

From 2010 through the first half of 2012, New York State spent roughly $100 million on Medicaid incentives

through the PMPM add‐on, which Medicaid managed care plans were required to pass directly through to

the providers. Only about $4 million was distributed through fee for service (FFS) increases, in part

reflecting the fact that most Medicaid members receive their care through health plans.

In addition to the incentive program, NYSDOH invested nearly $170 million in 20 projects designed to

expand PCMH, care coordination, health information exchange and other initiatives through the Health

Care Efficiency and Affordability Law (HEAL), which provided grant funding to build health information

technology and PCMH infrastructure throughout New York State. The Adirondacks Medical Home

Demonstration, Primary Care Information Project, and P2 were among those projects supported by HEAL

funds.

Timeframe: Started in 2010 and on‐going

Location: Statewide

NewYorkStateDepartmentofHealth

28

Recognizing that PCMH recognition

captures a “moment in time,”

NYSDOH is raising the bar on

incentive payments quality

measures, equivocal on cost and

either positive or unchanged with

respect to patient experience.

Size today: Approximately 1.8 million Medicaid members receive their primary care in a PCMH (mostly

NCQA Level 3), with over 5,000 clinicians and 460 practices receiving incentive payments. All Medicaid

managed care health plans participate.

Interviewees: Foster Gesten, MD, Medical Director, Office of Quality and Patient Safety, NYS Department

of Health; Marietta Angelotti, MD, Associate Medical Director, Office of Quality and Patient Safety, NYS

DOH; Lindsay Cogan, Research Scientist, Office of Quality and Patient Safety and Division of Quality and

Evaluation, NYS DOH

________

Implementation: Moving beyond the snapshot

NYSDOH recognizes that NCQA PCMH recognition is a necessary, but insufficient tool to transform primary

care. Many high‐performing providers who have been practicing like a medical home for years consider

NCQA recognition not much more than an acknowledgment of their current state. Others have used the

recognition process to change fundamentally how they practice. But many still are on the “hamster

wheel,” barely aware of their NCQA status and providing day to day medical services to patients in an

increasingly challenging environment. For NYSDOH, this leads to the concern that NCQA recognition

captures a moment in time but does not assure that “they are doing all of those things all the time every

day.”

Measurement: PCMH uptake strong, but data challenges abound

NYSDOH is undertaking a number of activities to evaluate the

impact of its initiatives, including the impact of PCMH on quality

of care, cost/utilization, and patient/provider experience.

Results so far are generally positive with respect to quality

measures, equivocal on cost and either positive or unchanged

with respect to patient experience. While savings or clear

reductions in preventable hospitalizations or emergency room

visits have not yet been documented, PCMH implementation in

NYS is still in its early phase. The general perception is that

practices that are both PCMH recognized and part of a larger

medical home initiative (with other payers or programs) appear

to have a greater level of engagement and support that will

probably contribute to better outcomes.

Like other PCMH initiatives, NYSHF faces challenges in evaluating impact. In this case, challenges relate to

adjustment for practice and patient characteristics, as well as determining the appropriate post‐PCMH

recognition time frame in which to expect a change in outcomes. For instance, “attributing” outcomes to a

particular provider or provider type can be difficult, since providers can practice in more than one location,

and patients can receive care (including but not limited to primary care) from more than one provider in

more than one setting, thereby ‘diluting’ the specific impact of a PCMH practice.


29

PCMH is woven throughout New

York’s $10 billion Medicaid Waiver

Payment: Raising the bar to move beyond one‐time recognition

NYSDOH is planning to raise the bar required to receive incentive payments. Starting in 2013, DOH will no

longer pay for providers who only have reached PCMH Level 1. NYSDOH is also considering paying

differentially for practices that become recognized under the 2011 NCQA standards rather than the 2008

standards to encourage practices to meet the more rigorous requirements.

Finally, NYSDOH may designate some portion of the payment to reflect quality reporting and

“performance.” This might be rolled out over several years, moving from simple reporting on valid

measures to improvement and/or meeting performance targets. NYSDOH believes this will help practices

move beyond the one‐time NCQA recognition toward an ongoing process of improvement.

Moving Forward: A vocabulary for quality, a vehicle for primary care investment

One of the key benefits of using the NCQA PCMH recognition program is that it provided some framework

from which to make primary care investment and a nomenclature to identity and discuss what quality

primary care looks like. This will be particularly valuable as New York State continues to make substantial

primary care investments through payment increases and infrastructure improvement.

More robust payment and delivery system changes are essential to achieving the Triple Aim and sustaining

it in the long run, and PCMH is increasingly becoming an important element of Governor Andrew Cuomo’s

strategy to “redesign Medicaid.”

Besides strengthening the Medicaid incentive program, New York is investing $250 million in federal

Medicaid funds to help New York’s hospitals to transform their ambulatory training sites into medical

homes, and develop residency teaching programs that train “PCMH ready” physicians. In New York City,

hospital clinics deliver more primary care to underserved communities than any other provider type.

Even more substantially, PCMH is woven throughout New York’s

Medicaid waiver, which the State is seeking to help transform its

Medicaid program. The waiver would allow New York to invest

$10 billion in a variety of health system and payment reform

programs that New York has identified as important to achieving

the Triple Aim.

One of the waiver’s objectives is “care management for all,” meaning universal access to a PCMH for every

Medicaid enrollee, and more intensive “health homes” for patients with multiple chronic conditions. To

achieve this, substantial funds would be made available for technical assistance to help providers transform

their practices and sustain PCMH; training (and retraining) the healthcare workforce in emerging models of

collaborative, interdisciplinary and team‐based care; and helping New York’s public hospitals develop

PCMH primary care for the uninsured.


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New York City Department of Health and Mental Hygiene Primary Care Information Project www.nyc.gov/html/doh/html/pcip/pcmh.shtmlwww.nycreach.org

Overview:

Goal: To improve population health through health information technology and data exchange.

Summary: The Primary Care Information Project (PCIP) is a bureau of the New York City Department of

Health and Mental Hygiene (NYCDOHMH) whose main mission is to improve population health through

health information technology and data exchange. PCIP can be categorized as a technical assistance

provider and subject matter expert, helping large and small primary care practices implement prevention‐

oriented EHR with built‐in core functionality (like quality measure calculations, registry functions, and

chronic‐disease focused clinical decision support).

In 2008, PCIP began incorporating PCMH transformation into its quality improvement work and worked

with NCQA to be recognized as a multi‐site applicant. This status allowed PCIP to create a single application

allowing qualified practices to receive Level 1 recognition based on having functionality present in the EHR.

PCIP would then work with the practices to demonstrate their use of this functionality, as well as to

implement patient centered work‐flows like improved access, quality reporting and patient engagement,

facilitating practices’ ability to gain additional points and reach higher levels of PCMH. This work was

initially funded largely through PCIP’s technical assistance program, and later through a $9.9 million

NYSDOH HEAL grant.

PCIP assisted most practices with 2008 NCQA PCMH standards and later a few with 2011 standards. Health

outcomes achieved to date include increased hemoglobin A1C testing, control of blood pressure to less

than 140/90 mmHg (130/80 for high‐risk patients), and increased documentation of smoking status as well

as delivery of smoking cessation interventions.

Timeframe: Started in 2008 and on‐going.

Location: New York City

Size today: Over 900 practices and almost 8,000 providers participate in PCIP programs. 164 practices/269

providers received Level 1; 23 practices/38 providers received Level 2, and 145 practices/ 581 providers

received Level 3 NCQA recognition.

Interviewees: Amanda Parsons, MD, Deputy Commissioner, New York City Department of Health and

Mental Hygiene (DOHMH) Division of Health Care Access and Improvement; Elizabeth Wolff, MD, MPA,

Executive Director of Quality Improvement & Health Outcomes, Bureau of the Primary Care Information

Project (PCIP)

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PCIP engages with practices most

committed to succeeding

________

Implementation: Challenges assisting leadership and staff

PCIP has established a team of field staff to work with primary care practices to help adopt EHR, connect to

health information exchanges, use registry functions to proactively manage the health of their patient

population, and participate in state or federal incentive programs.

Field staff work is often challenging and requires patience, resilience and perseverance. Sometimes, PCIP

staff show up at a practice to find that the physician has forgotten their visit or is too busy to participate in

the visit, forcing the PCIP staff to either wait (sometimes several hours) or to try to work with the other

staff present. Other challenges include practices that don’t implement the recommended changes

between site visits, or who revert back to the old workflows that were more familiar or comfortable to

them.

Many practices, particularly the independent small physician offices, do not have structured quality

improvement efforts or dedicated quality improvement staff. The front desk staff often plays a key role in

many of the aspects of PCMH, like care coordination, quality reporting, and referral management. But for

many small practices, that staff is also the office manager, receptionist and biller, leaving very little time to

participate in patient‐centered care processes. In addition, many providers did not feel comfortable

overseeing these activities, given their own lack of experience with them. As such, it is helpful to have PCIP

staff demonstrate various other models and work flows, and to provide on‐site guidance to ancillary staff

on best practices.

The overwhelming majority of practices can use the PCMH

concepts to make improvements both large and small. PCIP

found that some practices may be set in their current routine and

not ready to make the transformation. While they try to educate

these practices on the value of PCMH models, given limited

resources, PCIP has stratified the practices, engaging those who are most committed to succeed, while

postponing others who are not yet willing to commit the necessary resources.

Measurement: Tracking Medical Home‐ness and getting accurate data

As part of the information feedback process, PCIP provides dashboards for those practices that transmit

data to PCIP on a monthly basis. These dashboards show several EHR utilization and quality of care

measures, such as documentation of blood pressure in the vitals portion of the medical record and the

corollary, blood pressure control. For practices that do not receive dashboards, field staff show providers

how to utilize the EHR’s quality measurement and registry functions to generate lists of patients that may

have missed visits, or need further follow‐up or care.

PCIP says it is difficult to track and measure ongoing medical home‐ness after the practice has been

recognized. For example:

Care coordination: There is no widely accepted set of measures to effectively assess whether care is

coordinated. For example, if a patient was referred for a mammogram, there is no ability to track whether

the patient received the mammogram, whether the report was done correctly, and whether the report was


32

PCIP would like to explore a cross‐

payer program if payers are willing

to collaborate

sent to the primary care physician and was filed in the right place. To counter this, PCIP instructs practices

to follow up on referrals and tests and enter results in structured fields in the EHR. In addition, PCIP is

working on defining quality measures using more comprehensive data sources like Regional Health

Information Organizations (RHIOs) to widen the lens on care coordination.

Patient Experience: PCIP and most providers do not get the results of patient satisfaction surveys, so it is

difficult to determine how or if the patient had a better care experience. Though providers have the ability

to encourage the use and communication with patients through the “patient portal” in the EHR, it is only

good for assessing one aspect of patient engagement. Currently, satisfaction or clear communication with

patients has not been measured or tracked by practices or PCIP.

Payment: Bringing payers along, and preparing for PCMH changes

Currently, PCIP activities are supported by funding from New York City, New York State, and the federal

government. PCIP also established New York City’s regional

extension center, NYC REACH. As not all providers are eligible

for support from current funding sources, NYC REACH is piloting

a fee‐for‐service model for technical assistance that would be

available to all, and subsidized through grants or contracts with

their parties if available. Having supported the EHR adoption

and PCMH recognition of so many practices, PCIP has an interest

in seeing other payers invest in them as well. PCIP worked closely with the NYSDOH PCMH Medicaid

initiative, and helped advise HIP/GHI towards the end of their PCMH pilot. PCIP also helped recruit

practices for Empire’s PCMH initiative, and continues to advise on programs for advancing primary care.

PCIP is talking with payers to explore a cross‐payer program to support practices in achieving PCMH

designation, but has found that most payers seem only interested in working with their own subset of

patients and developing their own sets of standards and measures.

The NYSDOH’s decision to stop making incentive payments for Level 1 PCMH providers will impact the large

majority of practices served by PCIP. Though many are applying for a higher level of recognition, they will

lose their enhanced payments unless they achieve the higher recognition. PCIP’s experience has been that

NCQA Level 1 has been a good stepping stone to Level 3 and being reimbursed for the progress has always

been helpful to engaging interest and working towards change.

Moving Forward: Get the patient involved

PCIP will continue to work with practices on EHR, workflows and payment reform. They have found this a

productive strategy for NYCDOHMH– which is typically removed from actual patient care – to improve the

care delivery system. PCIP also believes that patients need more awareness of the PCMH concept and that

it can be used to better engage patients in their health care decisions by highlighting the “patient

centeredness” of the practices they select. For instance, PCMH recognition could be displayed at a practice,

or on a doctor‐finder website, so that rather than selecting providers based on likability and convenience,

patients can select providers who are better organized, coordinated, and who offer a better patient care

experience. PCIP believes this is can help how PCMH become more sustainable and successful.


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P2 Collaborative of Western New York www.p2wny.org

Overview:

Goals: Establish a community‐based approach to providing quality improvement, change management and

technical assistance resources to assist health care practices in achieving PCMH.

Summary: P2 (Pursuing Perfection) Collaborative of Western New York is a not‐for‐profit organization

dedicated to improving the health of people in Western New York. P² is one of 16 organizations in the

country selected by the Robert Wood Johnson Foundation for its Aligning Forces for Quality (AF4Q)

program, which gives it access to national experts, a wide array of technical assistance and opportunities to

interact with decision makers working towards health care reform nationally.

With support from the Robert Wood Johnson Foundation, New York State (HEAL grant) and federal

government and local community organizations, the P2 Collaborative has been working to establish a

community‐based approach to providing quality improvement, change management and technical

assistance resources to assist health care practices in achieving PCMH.

The P2 Collaborative uses a Community Extender Model to serve the practices in the region. It serves as the

coordinator of services to primary care practices throughout Western New York, subcontracting with

Community Based Extenders that cover the eight counties in the region, who in turn hired locally based

quality improvement resources, called Practice Enhancement Associates (PEAs). As coordinator, convener,

facilitator and conduit for funding, the P2 Collaborative is in a position to help all levels of the healthcare

delivery system improve, coordinating physicians, practices, hospitals, consumers, businesses, payers and

local and state government to gain significant buy‐in throughout the transformation process.

Out of 42 practice sites that were recruited through HEAL 10 and that received technical assistance services

through the PEAs and the P2 network, all but seven achieved NCQA recognition (the majority at Level 3).

These practices have reported positive clinical outcomes in diabetes management, improved access and

workflows, and increased health screenings. However, since the program is new, there are relatively few

quality measures available to analyze their program.

Timeframe: Started in 2010; on‐going

Size today: 35 out of 42 targeted practices P2 worked with received PCMH recognition, most NCQA Level 3.

Location: Eight counties in western New York that include rural communities and the cities of Buffalo and

Niagara Falls (Niagara, Erie, Orleans, Genesee, Wyoming, Chautauqua, Cattaraugus, and Allegany). This

region has twenty‐five hospitals and over 1,000 primary care providers.

Interviewees: Shelley Hirshberg, P2 Executive Director; Kate Ebersole, P2 Director Regional Quality

Improvement

________

Implementation: A process built on trust and understanding

The P2 Collaborative reports that one of the most significant challenges is for practices to admit there is a

challenge. PCMH requires major culture change that must be worked through, not only with the providers

but also with their entire practice staff, in order to effectively implement PCMH. P2 says it is important to

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P2 developed an ROI calculator to

show practices what they would

earn as a PCMH

identify “pockets of resistance” that could slow down the PCMH enterprise. It encountered several cases

where the physician leading the practice was the largest barrier to change, even if the staff was eager to

move forward. P2 also found particular challenges in hospital‐owned practices where decisions are often

made at the hospital level, creating resistance at the practice level.

Alignment of financial incentive provides a major breakthrough. Many practices were already on the path

to achieving MU standards and at first saw PCMH as yet another requirement being layered on. When P2

was able to demonstrate that PCMH recognition led to increased funding and was well aligned with MU

requirements adoption increased significantly. To assist the effort, P2 developed a return on investment

calculator, which uses inputs like patient panel, insurance payer mix, and incentive payments to calculate

additional revenue practices could expect to earn by pursuing PCMH and/or MU.

P2 says that it takes slow, methodical negotiation with the decision makers to bring them on board. The

process must align and empower employees and get everyone’s support on a common goal, a process

which takes a significant amount of time, energy and expertise that is not always available, particularly in a

busy practice.

Most practices have come a long way, recognizing the need for

strong workflow processes, looking at scheduling and access, and

understanding that these are necessary elements to improve the

practice. Ultimately, the changes and developments also require

a great deal of trust – in the quality improvement consultants and

PCMH itself.

Measurement: Lack of patient registries hampers population management

A significant barrier to transformation was the ability of the practices to develop and use patient registries.

In general, EHR systems are not readily usable for population management, disease management or quality

improvement. P2 suggests alternative solutions such as middleware programs that can pull registry data for

population health management.

Moving Forward: Sustainable PCMH through health planning, but payers need to contribute

But the medical home model is taking hold, and P2 believes that most of the primary care

physicians in Western New York have achieved some level of PCMH recognition and are engaged in other

important Triple Aim activities. This is in no small part because of substantial regional initiatives focused on

health improvement. In addition to P2, Western New York is developing a Health Information Exchange

through HEALTHeLINK, the regional health information organization, and is New York State’s only “Beacon

Community,” with goals to reduce hospital and ER use, improve diabetes care, reduce health disparities and

expand consumer access to health information.

Payers are also beginning to roll out new payment models. Following a three‐year study that found

marked reductions in diabetes, cardiovascular risk and ER utilization among PCMH providers, Independent

Health, which covers 370,000 lives and 1,200 primary care physicians in Western New York, is moving

beyond fee‐for‐service to a new reimbursement model. Independent Health’s “Primary Connections”

includes pre‐paid care management payments; prospective payments for practicing as a PCMH;

retrospective payments for meeting quality, satisfaction and efficiency goals; and shared savings

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opportunities for reducing total cost of the patient’s care. The new model is fostering alliances among

independent primary care practices, which are seeing the financial benefit of sharing resources (i.e. care

coordinators, dieticians, behavioral health providers) and developing strategies for working with hospitals,

specialists and other providers. vi

Health plans’ embrace of the medical home model validates P2’s past work with practices, as these

practices are more prepared to work collaboratively and participate more fully in new payment models. It

will also likely make P2’s work easier going forward, since there will be less resistance and more incentive

for providers to transform their practices.

But P2 sees gaps as well. One is the concern that safety net primary care providers don’t get left

behind, both in terms of transforming their practices and linking them to robust payment models offered

by commercial plans. There is also a need to look at the region as a whole, identify problem areas, and

ensure that resources and initiatives are being coordinated effectively.

P2 serves as the regional health planning and improvement organization for Western New York

under a health planning vision that seeks greater stakeholder involvement, accountability, and alignment

with New York’s triple aim goals. They hope the regional community based extender model they developed

will be an essential component to helping stakeholders adopt and sustain initiatives that will lead to better

health outcomes and lower costs.

P2Collaborative

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Works Cited iKaye, N., Buxbaum, J., & Takach, M. (2011). Building Medical Homes: Lessons from Eight States with Emerging Programs. Retrieved from http://www.commonwealthfund.org/Publications/Fund‐Reports/2011/Dec/Building‐Medical‐Homes.aspx ii Neilson, M., Langer, B., Zema, C., Hacker, T., & Grundy, P. (2012). Benefits of Implementing the Primary Care Patient‐Centered Medical Home: A Review on Cost & Quality Results. Retrieved from: http://www.pcpcc.net/guide/benefits‐implementing‐pcmh iii Kaye, N., Buxbaum, J., & Takach, M., 2011 iv DeVries, A., Chia‐Hsuan, W.L., Sridhar, G., Hummel, J.R., Briedbart, S., & Barron, J.J. (2012). Impact of Medical Home on Quality, Healthcare Utilization, and Costs. Am J Manag Care, 18(9):534‐544. Retrieved from: http://www.ajmc.com/publications/issue/2012/2012‐9‐vol18‐n9/Impact‐of‐Medical‐Homes‐on‐Quality‐Healthcare‐Utilization‐and‐Costs v Kaye, N., Buxbaum, J., & Takach, M., 2011 vi Foels, T. November 14, 2012, “Redefining the Role of Primary Care: The Primary Connection”, Money Changes

Everything: Creating Payment Reform in New York State, NYS Health Foundation. New York, NY. Retrieved from

http://nyshealthfoundation.org/news‐events/events/nyshealth‐conference‐money‐changes‐everything‐creating‐

payment‐reform‐in‐ne

Additional Resources

Impact of Medical Homes on Quality, Healthcare Utilization, and Cost (2011) American Journal of Managed Care

Retrieved from: http://www.ajmc.com/publications/issue/2012/2012‐9‐vol18‐n9/Impact‐of‐Medical‐Homes‐on‐

Quality‐Healthcare‐Utilization‐and‐Costs

Early Results Show WellPoint’s Patient‐Centered Medical Home Pilots Have Met Some Goals For Costs, Utilization,

And Quality (2012) Health Affairs

Retrieved from: http://content.healthaffairs.org/content/31/9/2002.abstract

The Patient Centered Medical Home: Taking a Model to Scale in New York (2011) United Hospital Fund

Retrieved from: http://www.uhfnyc.org/assets/956

Building The Scaffold To Improve Health Care Quality In Western New York (2012) Health Affairs

Retrieved from:

http://content.healthaffairs.org/content/31/3/636.full?ijkey=NVwamV0X/LzwQ&keytype=ref&siteid=healthaff

Patient‐Centered Medical‐Home Pilot Demonstrations in New York: No Longer a Leap of Faith (2011) Rockefeller

Institute of Government

Retrieved from: http://www.rockinst.org/pdf/health_care/2011‐02‐03‐Patient‐Centered_Medical5.pdf

building new york's medical homes

Documents

mphce acknowledgements