Congressional Staff Briefing

1
Redesigning Federal Policies to Support a
Patient-Centered Medical Home

• Congressional Staff Briefing
• 110th Congress
• Bob Doherty, SVP
• Governmental Affairs and Public Policy
• March 23, 2007

2
What is patient-centered care?

• Institute of Medicine defines patient-centered
  as providing care that is respectful of and
  responsive to individual patient preferences,
  needs, and values, and ensuring that patient
  values guide all clinical decisions
• INSTITUTE OF MEDICINE, CROSSING THE QUALITY
  CHASM A NEW HEALTH SYSTEM FOR THE 21ST CENTURY,
  March 2001

3
What are the key attributes of patient-centered
care?

• Commonwealth Fund
• superb access to care
• patient engagement
• clinical information systems
• care coordination
• integrated and comprehensive care
• smooth transfer of information
• ongoing public information
• publicly available information to choose a
  practice and physician
• Davis, Schoenbaum, Audet, A 2020 Vision of
  Patient-Centered Primary Care, Journal of General
  Internal Medicine, October, 2005

4
What is a patient-centered medical home (PCMH)?

• Organizes care around the relationship between a
  patient and a personal physician who takes care
  of the whole person, within a practice setting
  that uses systems-based tools to consistently
  deliver the key attributes of patient-centered
  care
• Practices would voluntarily seek recognition as a
  PCMH
• Patients would voluntarily choose to select a
  personal physician in a PCMH
• PCMHs would be supported by a better payment
  model

5
Patient-centered medical home has broad support
from physicians and employers

• Key elements of a PCMH are described in a joint
  statement of principles from ACP, the American
  Academy of Family Physicians, American Academy of
  Pediatrics, and the American Osteopathic
  Association
• Combined membership is over 330,000
• Model is supported by the National Business Group
  on Health, ERISA Industry Committee, IBM, and
  other employers

6
How would a PCMH work?

• Patients voluntarily choose to receive care
  through a physician practice (their medical
  home) that is organized to provide
  patient-centered services
• Personal physician
• Physician directed medical practice team
• Whole person orientation
• Care is coordinated and/or integrated
• Patients are partners in decision-making and
  their feedback is sought
• Systems-based approach

7
PCMHs would go through a voluntary qualification
process

• ACP, AAFP, AOA, and AAP are developing a
  voluntary process based on the NCQAs Physicians
  Practice Connection Modules
• Recognition as a PCMH would provide purchasers
  (employers, government) with upfront transparency
  that the practice has the capabilities needed
• Qualified PCMHs would also be accountable by
  voluntarily reporting on evidence-based clinical
  and patient experience measures

8
What types of systems would be used?

• Qualified PCMH practices would use systems to
  deliver patient-centered care
• Patient registries
• Evidence-based clinical decision support
• Secure e-mail
• Open scheduling and group visits
• Remote monitoring
• Leading to a fully functional EHR that
  incorporates registries, decision support,
  interoperability, and quality measurement and
  reporting

9
The patient-centered medical home is not defined
by specialty

• Any physician who has the training and experience
  to provide first contact, continuous and
  comprehensive care could be the patients
  personal physician
• General internists, family physicians and
  pediatricians have such training
• Physicians who limit care to particular organ
  systems, disease, or procedures are less likely
  to have the whole person orientation needed
• In some cases, the most qualified personal
  physician to take care of the whole patient
  will be a subspecialist or specialist

10
The PCMH is a care facilitator, not a gatekeeper

• The goal is to not to restrict access but to
  facilitate and integrate specialty care with the
  whole person perspective provided by a PCMH
• The PCMH will facilitate appropriate referrals,
  sharing of information, and coordination of
  care among a multidisciplinary team through use
  of HIT, established relationships between team
  members, and evidence-based referral protocols
• Patients may see a specialist at any time without
  prior approval
• The PCMH will integrate disease management
  support into the practice itself
• Patients are not locked into the PCMH

11
The PCMH is based on evidence of successful
models for improving care

• Patient-centered primary care has been
  implemented successfully in other nations that
  have better overall quality scores and lower
  costs (1)
• Within the U.S., states that rely more on primary
  care have better quality, lower overall Medicare
  costs, fewer ICU admissions and deaths and lower
  utilization (2)
• Effective care coordination in the ambulatory
  setting can reduce hospital admissions and
  re-admissions for chronic illnesses (such as
  diabetes, CHF) (3)
• (1) Starfield, presentation to Commonwealth Fund
  Roundtable on Primary Care, October 2006
• (2) Dartmouth Atlas, Fall, 2006
• (3) Commonwealth Fund, Chartbook on Medicare,
  2006

12
PCMH will accelerate the use of HIT and practice
transformation

• Patient-centeredness, shared decision making,
  teaming, outcome responsibility, the chronic care
  model, and disease management are among the
  proposals to transform medical practice. The
  EHRs greatest promise arguably lies in the
  support of these initiatives, versus the prospect
  of less efficiency, greater cost, inconsistent
  quality, and unchanged malpractice burdens
  resulting from simple engraftment onto the
  current health care system.
• Sidorov, It Aint Necessarily So, The
  Electronic Health Record and the Unlikely
  Prospect of Reducing Health Care Costs Health
  Affairs, Volume 25, Number 4, 2006

13
The PCMH must be supported by a different payment
model

• Physicians in a PCMH would not be paid solely on
  volume
• Instead, payment would be based on
• The value of the physician and clinical staff
  outside of a face-to-face visit
• The systems acquired by the practice
• Shared savings such as by reducing hospital
  admissions
• Performance on quality, cost of care, and patient
  experience measures

14
Proposed payment model for a PCMH

• Bundled, severity-adjusted care coordination fee
  paid on a monthly basis for the following
  components
• the physician and non-physician clinical staff
  work required to manage care outside a
  face-to-face visit
• the health information technology and system
  redesign incurred by the practice
• Combined with per visit FFS payment and
• Performance based bonus payments based on
  reporting on evidence based measures of care

15
How can Congress advance the PCMH?

• Provide oversight of Medicare medical home demo
• Repeal the SGR, improve accuracy of payments, and
  fund quality improvement activities
• Create targeted incentives for physicians to
  acquire HIT to facilitate patient-centric care
• Direct Medicare to pay for care coordination
• Break down Medicare silos and influence budget
  rules to account for total program savings
• Support state initiatives to redesign health care
  around a PCMH

16
Pathway to patient-centric careMedicare medical
home demonstration project

• Mandated by the Tax Relief and Health Act of 2006
• Redesign the health care delivery system to
  provide targeted, accessible and continuous and
  coordinated family-centered care to high need
  populations
• Include urban, rural and underserved areas in a
  total of no more than eight states
• Include practices with fewer than three FTE
  physicians as well as physicians in larger
  practices in rural and underserved areas

17
Medicare medical home demo

• Care management fee to personal physicians
  providing care under the project, using the
  relative value scale (RUC) processes to develop a
  care management fee code and a value for such
  code
• Practices get 80 of shared savings attributable
  to the medical home, as reduced by the total care
  management fees paid to the medical home
• The amount of such reductions in expenditures
  will be determined using assumptions of
  reductions in the occurrences of health
  complications, hospital rates, medical errors and
  adverse drug reactions

18
Medicare medical home demo

• Congress should exercise oversight to assure that
  implementation of the demo is not delayed by CMS
  and OMB
• Preliminary discussions with CMS indicate that
  the demo wont start until 2009, meaning results
  wont be available until 2012 or later
• Congress should pursue multiple pathways rather
  than waiting on the demo

19
Pathway to patient-centric careEliminate the
SGR and improve accuracy of payments

• If Congress does not act, the SGR will trigger an
  across-the-board Medicare fee cut to doctors in
  2008, and cuts of 40 or more over the next
  several years
• Continued payment cuts will create access
  problems, lead to cost shifting, and make it
  impossible for physicians to acquire systems to
  deliver patient-centric care

20
Pathway to patient-centric careEliminate the
SGR and improve accuracy of payments

• Congress should repeal the SGR and replace it
  with an update framework that
• Provides positive updates to all physicians
• Allocates a separate pool of dollars to support
  physician-led performance improvement initiatives
  with greatest impact on quality and costs
• Payments out of this pool should be on a weighted
  basis based on impact and systems required and
  pool of dollars should grow when savings are
  achieved in other parts of Medicare

21
Pathway to patient-centric careEliminate the
SGR and improve accuracy of payments

• Implement MedPAC recommendation to create a
  process to identify potentially mis-valued
  services for review by a multi-specialty expert
  process, based on evidence that work has
  decreased
• Any reductions in RVUs for mis-valued services
  should be redistributed back to the physician
  payment pool
• Direct CMS to review the accuracy of the practice
  expense RVUs, which determine more than 40 of
  the total approved payment per service

22
Pathway to patient-centered careProvide
targeted incentives for practice-level systems to
support better care

• Congress should
• Revamp the Physicians Quality Reporting
  Initiative to focus on acquiring the systems
  needed to support patient-centric care and
  reporting on measures for chronic illnesses
• Provide funding to physicians (grants, loans, tax
  incentives and changes in payment policies) for
  systems improvements to support patient-centered
  care in a medical home

23
Revamp the Medicare Physician Quality Reporting
Initiative (PQRI)

• Current program emphasizes paying physicians to
  report for the sake of reporting . . .
• . . . rather than rewarding them for reporting
  on structural and clinical measures that would
  advance patient-centric care focused on chronic
  illnesses

24
Revamp the Medicare Physician Quality Reporting
Initiative (PQRI)

• Redesign the PQRI to provided weighted
  performance payments for reporting on clinical
  measures that have the greatest impact on quality
  and costs (e.g. chronic diseases)
• And for reporting that they have the HIT and
  systems at the practice level needed to support
  patient-centric care (i.e. patient registries,
  evidence based clinical decision support, PHRs,
  secure email, fully functional EHR)

25
Pathway to patient-centric careProvide targeted
incentives for practice level systems to support
better care

• Provide low-interest loans, grants, and/or tax
  credits to help physicians in smaller practices
  afford the necessary technologies
• Establish through HIT legislation a grant program
  to support physicians who acquire the systems
  needed to function as a PCMH
• Direct HHS to create a modifier (add on) for
  Medicare office visit payments when supported by
  specific systems that support patient-centric care

26
Pathway to patient-centric careDirect Medicare
to pay for care coordination

• Direct Medicare to establish payment rules,
  codes, and RVUs for care coordination services
  billed on a FFS basis
• Care plan oversight for additional specified
  conditions
• Ongoing review of patient medical status and lab
  reports, and care plan modifications
• Physician e-mail and telephone consultation
  related to a care plan
• Physician review of remote monitoring
• Disease self-management training related to a
  care plan conducted by the physician or nurse
  with related follow-up
• Should be considered as a new benefit not
  requiring budget neutrality offset within
  physician payments

27
MedPAC supports focusing on chronic diseases and
care coordination

• Initially, policymakers might consider
  prioritizing the implementation of some
  pay-for-performance measures over others.
  Focusing on measures of high-cost, widespread,
  chronic conditions to maximize benefits to
  beneficiaries might be a good short-term
  strategy. Further, measures that reflect
  coordination between health care sectors (e.g.
  hospitals and physicians) will encourage and
  reward communication among providers, which may
  improve patient outcomes and reduce Medicare
  costs.
• Medicare Payment Advisory Commission, Report to
  Congress, March 2007

28
MedPAC supports payment for physician care
coordination

• Medicare should encourage coordination of care
  and provision of primary care . . .
• There are a number of care coordination and
  care management models Medicare could implement.
  For example, beneficiaries with chronic
  conditions could volunteer to see a specific
  physician or care provider for the complex
  condition that qualifies them to receive care
  coordination/care management. That physician
  would serve as a sort of medical home for the
  patient..
• Medicare Payment Advisory Commission, Testimony
  to the House Ways and Means Committee on
  Alternatives to the SGR, March 6. 2007

29
Payment for care coordination has broad support
within medicine

• Direct ing Medicare to pay medical practices
  for care coordination services that fall outside
  of a face-to-face encounter. System-wide
  savingssuch as reductions in hospital admissions
  and readmissions (Part A) and more effective use
  of pharmacologic therapies (Part D)achieved by
  these programs should be applied to funding the
  care coordination services. If enacted by
  Congress, such a policy should be considered a
  change in law that would not require a budget
  neutrality offset in the Medicare Physician Fee
  Schedule.
• Joint Recommendations to Congress On Eliminating
  the SGR and Supporting Efforts to Promote
  Health Care Quality and Appropriateness,
  Statement signed by AMA, AAFP, ACP, AAP, ACS,
  AOA and over 40 physician and other health
  professional groups, February 2007

30
Pathway to patient-centric care Break down
Medicare silos and influence budget rules

• Create budget reserve fund to support HIT with
  five year window to show impact
• Direct HHS to create a methodology to allow for
  shared savings resulting from care coordination
  and the PCMH (such as preventable hospital
  admissions)
• Revise Medicare physician fee schedule budget
  neutrality rules so that it takes into account
  the impact of proposed care coordination services
  on reducing total program costs
• Work with CBO to make changes in scoring rules
  to consider impact of new services and benefits
  on achieving program-wide savings and over a
  longer period of time

31
Pathway to patient-centric careSupport state
initiatives

• Louisiana, North Carolina, and Missouri are among
  states that have proposed to redesign care around
  a medical home
• December 2006 report by the Medicaid Commission
  to HHS recommends that all Medicaid enrollees
  receive care from a physician-directed medical
  home, without requiring a federal waiver
• Congress can support such efforts by
• Including language in the S-CHIP reauthorization
  to support states that organize care around a
  PCMH as part of a broader quality program
• Influencing CMS to grant waivers
• Providing funding to states to redesign Medicaid,
  S-CHIP, and programs for the uninsured around a
  PCMH

32
Summary

• Current payment policies by Medicare and other
  payers are dysfunctional because they reward the
  wrong kind of care high volume, fragmented and
  episodic care
• Congress should take steps to make fundamental
  changes to support patient-centric primary and
  principal care
• The patient-centered medical home is a
  transparent and accountable model for achieving
  better outcomes

33
Summary

• The PCMH does this by re-organizing care around
  the physician-patient relationship, supported by
  practice-level systems that facilitate care
  coordination, information sharing and integration
  among teams of health professionals, tracking of
  patients, access to evidence-based clinical
  decision support, and access to services

34
Summary

• Congress can advance the PCMH by
• Exercising oversight over the Medicare Medical
  Home demo while pursuing multiple pathways
• Eliminating the SGR and improving accuracy of
  payments
• Providing targeted incentives for physicians to
  acquire the systems needed to function as a PCMH
• Revamping the PQRI to focus on systems
  improvements and chronic diseases and vary
  payments based on impact
• Breaking down Medicare silos
• Revising budget rules
• Supporting state initiatives with waivers and
  funding

35
Conclusion

• Congress has an opportunity to join with the four
  physician organizations that represent those who
  provide primary and principal care to most
  Americans . . . and the nations largest
  employers
• To redesign federal policies to support
  patient-centered care
• through on ongoing relationship with a personal
  physician
• who accepts responsibility for their whole health
• In collaboration with other health care
  professionals
• supported by practice-level systems to facilitate
  coordination and sharing and integration of
  information (i.e. the PCMH)
• And a new payment structure that supports the
  value of the PCMH for patients and purchasers