The Patient Centered Medical Home

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The Patient Centered Medical Home

• Providing Patients Accessible, Continuous, and
  coordinated Care

Carol L. Henwood, D.O.,FACOFP Texas Osteopathic
Medical Association/Texas ACOFP June 20, 2008
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Patient-centered Primary Care Collaborative

• AARP
• AAFP
• ACOFP
• AOA
• CVS/Caremark
• Exelon
• General Motors
• IBM

• Medco
• NACHC
• NCQA
• Society of Teachers of Family Medicine
• Walgreens
• Wyeth

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• Personal Physician-Patient Relationship
• Physician-Directed Medical Practice
• Whole-Person Orientation
• Coordinated Care
• Hallmarks of Care
• Improved Quality and Safety
• Enhanced Access to Care
• Improved Physician Reimbursement

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• Virtually all payers piloting P4P programs that
  measure physician performance and offer financial
  incentives to those who meet quality targets
• 2005 107 programs 53 million
• 2008 160 programs 85 million

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• 95 Primary Care
• 52 Cardiology/Orthopedics/
• Ob-Gyn/Endocrinology
• 33 Hospitals

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Payers use cost and physician quality ratings to
divide physicians into two (2) or more groups.
This group-based system enables payers to make
ratings apparent to patients.TIERING STEERING
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Payers with Tiered Networks

• Aetna
• Cigna
• Humana
• United Health Care
• IBC

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Claims Data

• Volumes Too Low
• Incorrect/Incomplete Claims
• Not a Reflection of Clinical Outcomes

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• 83 of Medicare Beneficiaries AT LEAST ONE
  Chronic Condition
• 25 of THESE Medicare Beneficiaries
• Have FIVE OR MORE Chronic Conditions
• Fill AT LEAST FIFTY Prescriptions ANNUALLY
• Are Seen by AT LEAST ELEVEN Physicians ANNUALLY

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Cost and Quality
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Average Office Visit Length SEVEN MINUTES

• Rushed Visits
• Poor Patient Compliance
• Skyrocketing Costs
• Poor Outcomes

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Cholesterol Measured after MI

• 74.2 (2000)
• 80.3 (2003)

LDL after MI

• LDL
• LDL

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Quality Gap

• Disparity on a given measure between the national
  performance and the performance of the top 10
  of providers
• Airline Quality Gap 1
• Medical Quality Gap ????

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• Increasing Need for PCPs
• Population aged 85 and over will increase 50 in
  size from 2000-2010
• Decreasing Number PCPs
• Projected Shortage of 200,000 PCP by 2020
• PCPs in First-year Programs
• 15 (2007)
• 54 (1998)
• (NCQA 18 Jan 2008)

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Patients Are Dissatisfied!So are Doctors !

• Access
• Time
• Reimbursement

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• Higher Ratio of PCPs to Specialists Is Associated
  with Improved Health Outcomes and Lower Costs
  (Starfield)
• Adding 1 FP/10,000 People Is Associated with 70
  Fewer Deaths/100,000 People (NCQA 18 Jan 2008)
• 9 Reduction in Mortality

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• 20 Increase in Primary Care
• Decreased Cost of 684/Person
• 5 Decrease in Mortality/100,000 People
• 20 Increase in Specialist Care
• Increased Cost of 526/Person
• 2 Increase in Mortality/100,000 People

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Medicares P4P Project

• 2006 PVRL
• 16 Measures
• 2007 PQRI (July 1, 2007December 31, 2007
• 74 Measures
• 2008 PQRI (January 1, 2008 December 31, 2008)
• 119 Measures

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www.cms.hhs.gov/PQRI
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With Excerpts From
Centers for Medicare Medicaid Services
2008 Physician Quality Reporting Initiative
(PQRI) April 30, 2008 National Provider Call
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3 Claims-based Standard Options

• Submit claims for PFS-covered services furnished
  during applicable reporting period
• Reporting Options (3)
• January 1, 2008 December 31, 2008 (one-year)
• Claims-based reporting of Individual PQRI
  Measures
• Report each applicable measure
• if
• if 3, report at least 3 for 80 of patients
• July 1, 2008 December 31, 2008 (half-year)
• Claims-Based Reporting of Measures Groups
• 15 Consecutive Patients
• OR
• Claims-Based Reporting by Measures Groups
• for 80 of Eligible Patients
• Note Claims-based reporting for 6-month
  reporting period only available for
  reporting of Measures Groups

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Registry-based Measures Groups
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Measures Groups

• 4 Clinically Related Measures Groups
• Diabetes (5 measures)
• End Stage Renal Disease ESRD (4 measures )
• Chronic Kidney Disease CKD (4 measures)
• Preventive Care (9 measures)

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Measures Groups

• Diabetes Mellitus
• 1 Hgb A1c Poor Control
• 2 LDL Control
• 3 High Blood Pressure Control
• 117 Dilated Eye Exam
• 119 Urine Screening for Microalbumin

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Measures Groups

• End Stage Renal Disease ESRD
• 78 Vascular Access for Hemodialysis HD
  Patients
• 79 Influenza Vaccination
• 80 Plan of Care for Patients with Anemia
• 81 Plan of Care for Inadequate HD

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Measures Groups

• Chronic Kidney Disease CKD
• 120 ACE or ARB
• 121 Testing for Ca, Phos, IPTH, Lipids
• 122 Blood Pressure Management
• 123 Plan of Care Elevated Hgb for Patients on
  ESA

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Measures Groups

• Preventive Care
• 39 Screening/Therapy for Osteoporosis in Women
• 48 Assessment of Urinary Incontinence in Women
• 110 Influenza Vaccination
• 112 Screening Mammography
• 111 Pneumonia Vaccination for Patients 65 Years
  and Older
• 113 Colorectal Cancer Screening
• 114 Inquiry Regarding Tobacco Use
• 115 Advising Smokers to Quit
• 128 Weight Screening and Follow-up

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Payment

• EP must satisfactorily report under one method to
  qualify for 1.5 incentive
• CMS will review data submitted via all methods to
  determine satisfactory reporting and eligibility
• Maximum incentive payment 1.5 of total allowed
  PFS charges for Part B covered services for the
  applicable reporting period
• If qualify for more than one 2008 PQRI reporting
  method -- receive incentive for longest reporting
  period

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Medicare Reimbursement

• E/M Payment
• P4P Coefficient
• Medical Home Ranking

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Patient Practice ConnectionPatient Centered
Medical Home

• Validated, reliable web-based tool to measure the
  degree to which a practice is using the system in
  the PCMH Model
• Endorsed by ACP,AAFP,AAP,AOA to qualify practices
  in Patient Centered Medical Home
• (NCQA 18 Jan 2008)

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PPC-PCMH Scoring

• 9 Standards
• 100 Points
• Level of qualifying Points Must pass
• 
  elements at 50
• Level 3 75-100 10
  of 10
• Level 2 50-74 10
  of 10
• Level 1 25-49 5 of 10
• Not recognized 0-24

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Standard 1

• A. Has written standards for patient access
  and communication
• B. Uses data to show it meets its standards for
  patient access and communication
• Must Pass Element

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Standard 2 Patient Tracking and Registry
Functions

• A. Uses data systems for basic patient
  information
• B. Has clinical data system with clinical data
  in searchable data fields
• C. Uses the clinical data system
• D. Uses paper or electronic based charting
  tools to organize clinical information
• E. Uses data to identify important diagnoses
  and conditions in the practice
• F. Generates lists of patients and reminds
  patients and clinicians of services needed
• Must Pass Element

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Standard 3 Care Management

• A. Adopts and implements evidencebased
  guidelines for three conditions
• B. Generates reminders about preventative
• services for clinicians
• C. Uses non-physician staff to manage patient
  care
• D. Conducts case managementincluding care
  plans, assessing progress, addressing barriers
• E. Coordinates care/follow up for patients who
  receive care in inpatient and outpatient
  facilities
• Must Pass Element

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Standard 4 Patient Self-Management Support

• A. Assess language preference and other
  communication barriers
• B. Actively supports patient self-management
• Must Pass Element

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Standard 5 Electronic Prescribing

• A. Uses electronic system to write
  prescriptions
• B. Has electronic prescription writer with
  safety checks
• C. Has electronic prescription writer with
  cost checks

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Standard 6 Test Tracking

• A. Tracks tests and identifies abnormal results
  systematically
• B. Uses electronic systems to order and
  retrieve tests and flag duplicate tests
• Must Pass Elements

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Standard 7 Referral Tracking

• A. Tracks referrals using paper-based or
  electronic system
• Must Pass Element

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Standard 8 Performance Reporting and
Improvement

• A. Measures clinical and/or service
  performance by physicians across the practice
• B. Survey of patients care experiences
• C. Reports performance across the practice or
  by physician
• D. Sets goals and takes action to improve
  performance
• E. Produces reports using standardized
  measures
• F. Transmits reports with standardized measures
  electronically to external sources
• Must Pass Element

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Standard 9 Advanced Electronic Communications

• A. Availability of Interactive Website
• B. Electronic Patient Identification
• C. Electronic Care Management Support

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www.ncqa.org
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• QUALITY
• COST
• PATIENT SATISFACTION
• ???How Will You Measure-up???