THE PATIENTCENTERED MEDICAL HOME: ITS ROLE IN HEALTHCARE REFORM

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THE PATIENT-CENTERED MEDICAL HOME ITS ROLE IN
HEALTHCARE REFORM
Stephen M. Shortell, Ph.D. Blue Cross of
California Distinguished Professor of Health
Policy and Management Dean, School of Public
Health University of California-Berkeley Richard
and Barbara Hansen Leadership Award and
Lectureship
University of Iowa College of Public
Health Coralville, Iowa September 18, 2009
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Healthcare Reform (U.S.)

• Nearly 50 million uninsured

• 16 GDP
• Most expensive in world
• 2.4 trillion

• Bottom quartile on most health status measures
  for OECD nations
• 50/50 chance of getting recommended care

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We Have A Big Opportunity
Performance Measurement / Public Reporting /
Accountability
Improved Outcomes / Improved Value

• Capabilities
• EHRs
• Teams
• Continuous Improvement

• Incentives
• Payment Reform

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The Three Major Issues of Healthcare Reform

• Accessibility
• Affordability
• Sustainability
• The contribution of the patient-centered medical
  home (PCMH) is what it contributes to addressing
  these issues.

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Three Questions

• Given the shortage of primary care providers, can
  the PCMH respond to the increased demand for
  care?
• In what ways can the PCMH make care more
  affordable while maintaining or improving
  quality?
• To what extent can the PCMH help promote
  sustainable changes in how healthcare is
  delivered over time?

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What is the PCMH?

• An entity that provides patients with a primary
  care team that has the capabilities to provide
  personalized, whole person, coordinated care
  across conditions, episodes, providers, and
  settings over time.
• Endorsed and supported by the American College of
  Physicians, the American Academy of Family
  Physicians, the American Academy of Pediatrics,
  and the American Osteopathic Association

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Four Cornerstones
New Model Practice
Payment Reform
Patient-Centered Care
Primary Care
Source DR Rittenhouse and SM Shortell, The
Patient-Centered Medical Home Will It Stand the
Test of Health Reform? JAMA, May 20,
2009301(19)2038-2040.
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To succeed, it must be embedded within a
package of delivery system reform proposal
elements

• Payment Reform
• Capitation
• Bundled / Episode of Care Based Payment
• Care Coordination Bonuses and Between Visit
  Payment
• Pay For Performance
• Accountable Care Organizations (ACOs)
• Comparative Effectiveness Center
• Legal and Regulatory Reforms
• Electronic Health Records

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Payment Reform
FROM Fee-For-Service and Perverse Incentives for
Hospitals and Physicians TO Payment Models That
Reward Value Added Cost / Effective Care
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Accountable Care Organizations
To do this, you need organizational structures
that can accept and respond to the new payment
incentives ACOs are entities that accept
responsibility for the cost and quality of care
provided to a given population of patients and
provide the data on their performance Typically
include physician practices, at least one
hospital and could include nursing homes, home
health agencies and other provider organizations
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Five Different Models

• Integrated Delivery Systems (Kaiser-Permanente,
  Group Health Cooperative of Puget Sound, Henry
  Ford Health System, Intermountain Health System,
  Trinity Health System)
• Multi-Specialty Group Practices (Mayo Clinic,
  Billings Clinic, Cleveland Clinic, Virginia
  Mason, Marshfield Clinic)
• Physician Hospital Organizations (Advocate,
  Middlesex)
• Independent Practice Associations (IPAs Hill
  Physicians Group, Health Partners in Los Angeles,
  many others)
• Virtual Physician Organizations (Community Care
  of North Carolina, Grand Junction, Colorado,
  Humboldt County, California)

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An Example of Accountable Payment
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Key Linkage

• PCMHs are the basic Building blocks for ACOs.
• PCMHs are the foundation.
• ACOs and PCMHs are synergistic.

ACO
PCMH
PCMH
PCMH
PCMH
PCMH
Patient Population
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Patient-Centered Medical Home Potential
Eligibility Criteria NCQA
Source Oregon Health and Science University
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Criteria (1 Example, Total Category Points)
Total Possible Points gt 100
Source Oregon Health and Science University
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COLD WATER! Not many physician practices today
would meet the standards for becoming a PCMH.
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Highest and Lowest Performers on the
Patient-Centered Medical Home (PCMH) Index
According to the Size of the Medical Group
Source National Study of Physician
Organizations and the Management of Chronic
Illness, March 2006 - March 2007, UC-Berkeley,
School of Public Health. D.D. Rittenhouse, L.P.
Casalino, R.R. Gillies, S.M. Shortell, and B.
Lau. Measuring the Medical Home Infrastructure
in Large Medical Groups, Health Affairs.
September/October 2008, 27(5)1246-1258.
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What Is the Evidence?

• Quality of Care, Patient Experience, Care
  Coordination and Access Are Better
• Reductions in ER Visit and Hospitalizations
• At Least Cost Neutral
• Internationally, Systems with Greater Investment
  in Primary Care Have Better Health Outcomes at
  Lower Cost

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Some Specific Examples

• Group Health Cooperative of Puget Sound
• 29 reduction in ER visits 11 reduction in
  ambulatory care sensitive admissions versus
  control sizes
• Significantly higher patient experience scores
  and less staff burnout
• No increase in overall cost
• Now being implemented in all 26 primary care
  clinics serving 380,000 patients

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Some Specific Examples (Contd)

• Community Care of North Carolina
• 40 decrease in hospitalizations for asthma and
  11 lower ER visits
• Total savings to Medicaid and SCHIP Programs of
  135 million to 400 million
• Now involves 1300 community-based practice sites
  and approximately 4500 primary care clinicians
  throughout North Carolina

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Some Specific Examples (Contd)

• Geisinger Proven Health Navigator Model
• Statistically significant 14 reduction in
  hospital admissions relative to control and 9
  reduction in total costs at 24 months
• Estimated 3.7 million net savings for a ROI of gt
  2 to 1
• Colorado Medicaid and SCHIP
• Median annual costs of 785 for PCMH children
  versus 1000 for controls due to reductions in ER
  visits and hospitalizations

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Some Specific Examples (Contd)

• Intermountain Health Care
• Absolute reduction of 3.4 in 2 year mortality in
  comparison with control group focusing on
  high-risk elderly
• 10 relative reduction in hospitalizations and
  even greater among those with chronic illnesses.
  Net reduction in total costs of 640 per patient
  per year 1650 among highest risk patients
• Now being implemented in 75 practices in 6 states

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Patient-Centered Medical Home Design Principles
and Change Components

• PCMH Design Principles
• The relationship between the primary care
  physician and patient is at the core. The
  organization will align to promote and sustain
  this relationship.
• The primary care physician will be the leader of
  the clinical team, be responsible for
  coordination of services, and will collaborate
  with patients in care planning.
• Continuous healing relationships will be
  proactive and encompass all aspects of health and
  illness. Patients will be actively informed and
  encouraged to participate.
• Access will be centered on patients needs, be
  available by various modes 24/7, and maximize the
  use of technology.
• Clinical and business systems will align to
  achieve the most efficient, satisfying, and
  effective patient experiences.

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Patient-Centered Medical Home Design Principles
and Change Components (Contd)

• Structural and Team Change

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Patient-Centered Medical Home Design Principles
and Change Components (Contd)

• Point-of-Care Changes

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Patient-Centered Medical Home Design Principles
and Change Components (Contd)

• Patient Outreach Changes

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Patient-Centered Medical Home Design Principles
and Change Components (Contd)

• Management Changes

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• PCMHs can be a great source for collaborative
  education of patients, their families and their
  clinical team regarding the advances in
  evidence-based medicine and management. A home
  for continuous learning.

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• Ultimate success of the patient-centered medical
  home may lie in the aggregate response to the
  following question
• Is there anything at all that could have gone
  better today from your point of view in the care
  that you experienced?
• Don Bewick, What patient-centered care should
  mean confession of an extremist, Health
  Affairs, May 14, 2009.

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Sources

• Starfield, B., L. Shi, et al. Contribution of
  primary care to health systems and health.
  Milbank Q 200583(3)457-502.
• Reid R., Fishman P., Yu O., et al. A
  patient-centered medical home demonstration a
  prospective, quasi-experimental, before and after
  evaluation. Am J Managed Care 2009 (Sept issue
  in press).
• Steiner, B., et al. Community Care of North
  Carolina Improving care through community
  health networks. Ann Fam Med 20086361-367.
• Dorr, D., Wilcox, A., Brunker C., et al. The
  effect of technology-supported, multi-disease
  care management on the mortality and
  hospitalization of seniors. J Am Geriatr Soc.
  200856(12)2195-202. Finds updated for
  presentation at White House roundtable on
  Advanced Models on Primary Care, August 10, 2009.
• Rittenhouse, D., Casalino, L., Gillies, R.,
  Shortell, S., and Lau, B. Measuring the medical
  home infrastructure in large medical groups.
  Health Affairs. September/October 2008,
  27(5)1246-1258.
• Rittenhouse, D., and Shortell, S. The
  patient-centered medical home will it stand the
  test of health reform?. JAMA 2009301(19)2038-204
  0.

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• THANK YOU!