presented by christine hughes to the missouri association of osteopathic physicians and surgeons the...

Presented by Christine Hughes to the Missouri Association of Osteopathic Physicians and Surgeons

The Patient-Centered Medical Home

April 15, 2011

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Agenda

What is a Medical Home?

The Business Case for Developing Medical Homes

Key Lessons from Multi-Payer Medical Home Initiatives in the U.S.

Missouri Foundation for Health’s “Missouri Medical Home Collaborative”

Questions/Discussion

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Pediatric origins in 1960 with focus on children with special needs

NCQA physician recognition standards built off the Chronic Care Model which was developed by Dr. Ed Wagner

Joint Principles released in February 2007 by primary care professional organizations

NCQA physician recognition standards modified for PCMH with revised standards

Continuing and ongoing evolution

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Specific system changes (intense practice transformation) designed to result in:– informed activated patients and

proactive practice teams

– an improved system of care, leading to better quality and reduced costs

Foundation for developing Accountable Care Organizations

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What System Changes Differentiate a Medical Home from Traditional Primary Care?

Proactive, integrated delivery of care– Team-based care using evidence-based decision support– Population-based care– Proactive planned visits instead of reactive, episodic care– Integrated care management for high-risk patients– Coordinated care across all settings

Patient-centered care– Personal physician or other clinician (e.g., NP)– Support for self-management of chronic conditions (e.g.,

asthma, diabetes, heart disease)– Patient-centered practice orientation and communications– Enhanced access (e.g., expanded hours, use of email,

group visits)– Referral to community-based resources

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Examples of How PMCH Components Drive Systems Change1. Self-management support:

-- Involve the patient in goal setting, action planning, problem-solving and follow-up; track success; periodically re-set goals

– Select evidence-based approaches to engaging patients in self-management (e.g., motivational interviewing)

– Train the care team– Create patient outreach and office processes to engage and

motivate the patient at each point of interaction with the practice

2. Move from reactive to proactive care– Pre-plan key appointments by obtaining lab work in advance,

reaching out to the patient to identify key concerns/goals; care team defines goals for appointment

– Establish a system of group appointments

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PMCH Components Driving Systems Change

3. Population-based care and decision support: -- Develop electronic patient registries to compile and track key

data

-- Select and integrate evidence-based guidelines; share with patients to get buy-in

– Generate patient-specific reminders and alerts for providers and patients

– Produce population-based data and analysis, such as % of diabetics with A1c over 9%; % of patients with BP over 140/90

– Generate reports to support quality improvement processes– Adjust processes to improve quality

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PCMH Components Driving Systems Change

4. Care management of high-risk patients: – Develop care management capacity within practice– Work with payers to identify high-risk patients and coordinate

with payer case managers– Develop and implement tools to track and engage patients to

better manage their conditions

5. Enhanced access and communication:-- Understand the patient’s cultural orientation and values-- Identify and address medical and non-medical barriers to the

patient’s ability to follow a care plan-- Conduct group visits-- Use electronic/web-based communication and information-- Use care team members to provide services that do not require

MD/DO-level training

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Payment Reform

• Creates a culture that emphasizes high quality, integrated care – Payers provide incentives to encourage quality and

efficiency– Payers provide reimbursement for traditionally non-

reimbursable services, such as patient outreach, care coordination, and peer-based, self-management training

– Payers may also provide incentive payments linked to improved quality and efficiency or share savings generated by such care

Payment reform is essential for sustainability of system changes

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Research on Effectiveness of Medical Homes

May 2010 edition of Health Affairs examined issues associated with primary care, including the Medical Home as an approach to practice transformation

One article, “Driving Quality Gains and Cost Savings through Adoption of Medical Homes,”* examined annual outcomes of 7 successful Medical Home projects and tried to identify common success factors

Projects demonstrated both improved quality and reduced costs and provide suggested best practices

*Fields D, Leshen E and Patel K, “Driving Quality Gains and Cost Savings through Adoption of Medical

Homes.” Health Affairs, May 2010, Volume 29, Number 5, pages 819-826.

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Business Case for Medical Homes

Findings from most recent research of successful Medical Home models indicates reduced costs and improved patient health status– Costs compared to either control groups or historical trends

Savings are generally due to reduced use of ER and inpatient services

Changes observed for general primary care patient population and for populations of high-risk patients

Changes also seen among privately insured, Medicaid, SCHIP and Medicare populations

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Business Case Observations

Business case is growing more solid as we get more experience with Medical Homes

Growing evidence that there are key components at the practice level required for success, particularly:– Engaged leadership– Dedicated care managers– Expanded access– Performance management tools– Effective financial incentives

Ability to increase opportunities for success by designing a model based on best practices

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Medical Home Projects and Demonstrations

There are currently at least 28 multi-stakeholder PCMH projects underway in 21 states.

Medicare will join at least 6 of these in mid 2011.

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General Keys to Sustainability

Strong champions among stakeholders and within transforming practices

Adequate project management support for the duration of the initiative

Financial and non-financial support for provider adoption– Payment from payers– Technical assistance

Regular feedback to practices and stakeholders on performance improvement

Process for ensuring practice improvement

Durable cost savings and quality improvement will only happen when the care delivery process changes, and when patients are engaged in prevention and self-management.

Models are continuing to be refined in many ways

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What is Happening in Missouri?

Several practices independently seeking NCQA recognition

Several single-payor initiatives

Missouri Foundation for Health (MFH) hosting a multi-payor/stakeholder Collaborative (MMHC)

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Missouri Medical Home Collaborative (MMHC) – Activities to Date

MFH contracted with Bailit Health Purchasing to assess interest and readiness – Spring 2010

Conducted key stakeholder interviews and PCP provider survey – spring/summer 2010

MFH committed to convening a multi-stakeholder initiative and provide 2011 funding for:– Project Management of MMHC– Evaluation: Hire a contractor to develop an evaluation plan to

determine impact of initiative– Learning Collaborative(s): Hire a contractor to offer

intensive multi-day PCMH practice transformation trainings for primary care providers

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MMHC – Activities to Date continued

Established a planning council consisting of key stakeholders – November 2010

– Payers/Insurers (public and private)– Employers– Providers (Hospitals/Health Systems; PCP practices; FQHCs; RHCs)– “Thought Leaders”

Council met every 2 weeks to develop framework for Collaborative - November 2010 through January 2011

– Background and Proposed Approach– Collaborative goals and duration, defining and verifying Medical Home

Status– Payment model– Technical support for practices, clinical focus, practice participation

requirements– Consumer engagement, evaluation

Payment Model and ‘statewide’ expansion - February through April 2011– Payer only & payer/provider meetings to develop payment model– Coordination efforts with Health Care Foundation of Greater Kansas City – Steering Committee Formation

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Medical Home Initiative Framework:

Framework Document defines the following Critical Design Areas:

Defining medical home Supporting practice transformation Validating transformation Reforming payment Engaging patients Soliciting and selecting practices Evaluating impact

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Objectives of the Missouri Medical Home Collaborative (MMHC)

Design, implement and evaluate a Medical Home with the long-term goal of impacting all Missourians in all primary care practices

Sustainably promote practice transformation through both process change and payment reform with the goal of improving patient-specific and population-based quality of care, reducing costs, and improving patient experience.

Promote innovation in order to reach a broad spectrum of Missouri residents, including the under-insured and uninsured populations.

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MMHC Definition of the Medical Home:

Core competencies that practices must achieve in order to become a Medical Home: Personal patient - primary care clinician relationships; Comprehensive care coordination across all settings and providers; Care management for the highest risk patients; Whole patient orientation to care, including access to needed services, and an

understanding of and respect for cultural and linguistic preferences; Promotion of two-way communications and active involvement of patients in care

decisions and self-management of chronic conditions; Use of patient registries to proactively identify patient and population gaps in care

against evidence-based benchmarks; Adoption of Medical Home care processes, such as planned care at every visit,

development of patient self-management plans and risk assessment and tailored interventions, to minimize gaps in care;

Promotion of preventive care; Use of data reporting to promote quality improvement; Improve access to care through use of a variety of office-based and electronic-

based approaches; and Use of quality improvement strategies and techniques to promote continuous

improvement.

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MMHC Participating Practice Selection Criteria:

To apply to participate in the Collaborative, practices must have:– a substantial percentage of patients covered by participating payers,

– have strong engaged leadership,

– have patients assigned to individual primary care clinicians, and meet minimum access requirements.

– can not be implementing an EMR at the same time

At least 66% of selected practices must be MO HealthNet providers (either FFS or a network provider of a Missouri Medicaid managed care plan).

Ongoing Provider Participation Requirements: Practices selected to participate in the MMMC must achieve clearly defined interim transformation milestones.

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Practice Transformation

MMHC Clinical Approach: The practice transformation processes relative to the provision of care management services will be systematically rolled out as follows:

– adults with diabetes and cardiovascular disease, and children with asthma and mental health conditions (either ADHD or bipolar).

– highest risk patients, – other chronic conditions, beginning with the most

prevalent chronic conditions first, – healthy patients

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MMHC Technical Assistance

Each Learning Collaborative accommodates up to 50 practice sites, and includes:– a pre-work period – nine all-day learning sessions held over a 24-month period– inter-session conference calls to reinforce key lessons from the

learning sessions MFH has committed to funding at least one Learning Collaborative

and Health Care Foundation of Greater Kansas City expressed interest as well. Tentative Learning Collaboratives to be offered, depending on funding availability are:– CMHC September 2011– St. Louis area primary care practices November 2011– Kansas City area primary care practices Jan/Feb 2012– Mid-Missouri area primary care practices March/April 2012

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MMHC Consumer Engagement:

To develop an informed, engaged patient, participating practices will:– Develop consumer engagement skills, such as using

motivational interviewing, using tools to gauge a patient’s level of self-management readiness, and developing with the patient a self-management plan;

– Use educational materials to clarify health care roles and responsibilities;

– Obtain patient input on a regular basis regarding effectiveness of meeting patient-centered goals;

– Increase use of existing community-based resources; and– Integrate existing payer and employer consumer incentive

programs and wellness benefits into care plans.

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Validating Practice Transformation

Provides an external documentation of efforts

Required by payors to justify $ spent

Verification of Medical Homeness for MMHC: – Participating practices must obtain by month 18 of the

Collaborative Medical Home designation by an external accreditation body selected by the Council.

– NCQA is the most recognized accreditation body

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Payment Reform

Essential to sustainability of practice transformation Usually funded by payer participants for specified

time period with goal of instituting permanent changes when the evaluation demonstrates value

Most effective if a single payment model is used across payers

Requires governmental oversight to mitigate anti-trust risks while payers and providers work on a payment model

Need enough payer participation that at least 50% of a practice’s patient population is covered by the reformed payment arrangement

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Payment Reform: Types of Payments

Infrastructure payments to cover initial start-up costs, e.g., – Forming practice teams– Building and populating a patient registry – Attending learning collaborative sessions

Payments for Medical Home activities not traditionally reimbursed, such as:– Team meetings– Pre-planning key patient appointments– Care Coordination– Clinical Care Management – Producing patient registry and analyzing reports for QI purposes

Reward or incentive payments, such as P4P or shared savings, to align practice incentives with desired Medical Home performance

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MMHC Proposed Payment Model

Year 1: in addition to traditional FFS payments– pmpm payments to practices for traditionally non-reimbursed

medical home services– Pmpm payments for clinical care management for highest-risk

patients with some proposed stratification based on age of member

Year 2: pmpm payments continue so long as practice submits performance

data, attends learning collaborative, demonstrates transformation ; If perform well on quality measures and demonstrate savings then

performance incentive payment will begin based on savings from reduced ER visits and Inpatient admissions

prior yr compared to current year – adjusted for high-cost outliers both prior and measurement year; small practices grouped with other like practices; up to 40% on sliding care based on quality measures.

Separate shared savings calculations for Medicaid and commercial

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Next Steps

April through June 2011 Steering Committee meets five times to develop details regarding

participation requirements for providers and payment methodology Payer only meetings, as needed to address operational issues related

to payment model RFP released for Learning Collaborative Vendor MFH obtains payer engagement Council reconvenes 6/20/11 to review and approve work of Steering

Committee RFPs issued for learning collaborative vendor and evaluator contractor

June through September 2011 Request for application released for practices Development of Learning Collaborative curriculum Practices selected

October 2011 Learning Collaborative launched by beginning pre-work activities

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Questions/Discussion

presented by christine hughes to the missouri association of osteopathic physicians and surgeons the...

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