Presentation to Patient-Centric Primary Care Roundtable:

1
How Can the Federal Government Support
Patient-Centered Care?

• Presentation to Patient-Centric Primary Care
  Roundtable
• From Public Policy to Implementation
• Bob Doherty
• Senior Vice President
• Governmental Affairs and Public Policy
• American College of Physicians
• March 12, 2007

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Take home message

• Congress and CMS should create multiple pathways
  to support patient-centric care
• Implement the Medicare medical home demo
• Revamp the Medicare Physician Quality Reporting
  Initiative to focus on high impact measures and
  systems to support patient-centric care
  coordination
• Create additional incentives for physicians to
  acquire HIT to facilitate patient-centric care
• Eliminate the Medicare SGR and improve accuracy
  of payments
• Break down Medicare silos and change budget
  rules to account for total program savings
• Support state initiatives to redesign Medicaid
  and S-CHIP around the patient-centered medical
  home (PCMH)

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The Tax Relief and Health Care Act of 2006
includes a Medicare medical home demonstration
project

• Based on legislative language proposed by ACP and
  supported by AAFP
• Purpose of the demo is to redesign the health
  care delivery system to provide targeted,
  accessible and continuous and coordinated
  family-centered care to high need populations
  and under which
• Care management fees are paid to persons
  performing services as personal physicians
• Incentive payments are made to physicians
  participating in practices that provide services
  as a medical home
• Shall include urban, rural and underserved areas
  in a total of no more than eight states
• Shall be designed to include practices with fewer
  than three FTE physicians as well as physicians
  in larger practices in rural and underserved
  areas

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Medicare medical home demo

• High need population means individuals with
  multiple chronic diseases that require regular
  monitoring, advising or treatment
• Personal physician is defined as a board
  certified physician who provides first contact
  and continuous care for the individual under the
  physicians care and the physician has the
  staff and resources to manage the comprehensive
  and coordinated care of such individuals

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Medicare medical home demo

• A personal physician shall perform or provide for
  at least the following
• Advocates for and provides ongoing support,
  oversight and guidance to implement a plan of
  care that provides an integrated, coherent,
  cross-discipline plan for ongoing medical care
• Plan is developed in partnership with patients
  and includes all other physicians furnishing care
  to the patient involved
• Uses evidence-based medicine and clinical
  decision support tools at point of care
• Uses HIT that may include remote monitoring and
  patient registries
• Encourages patients to engage in the management
  of their own health through education and support
  systems

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Medicare medical home demo

• The Secretary shall provide for payment of a 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 dollars saved (such as Part
  A 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

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Medicare medical home demo

• Major design issues (value of the care
  coordination fee, shared savings methodologies,
  attribution, recruitment and qualifications of
  practices) remain to be worked out
• As a demo, the care coordination fee is not
  expected to require a budget neutrality offset
  in payments to doctors
• Preliminary discussions with CMS indicate that
  the demo will be launched on 1/1/09 and continue
  for three years, so results wont be known until
  2012

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Congress and CMS should pursue additional avenues
to promote patient-centric care

• Multiple pathways to enable patient-centric care
  will be more effective than relying only on the
  Medicare Medical Home demo
• Such pathways should accelerate redesign of
  payment and delivery systems to advance
  patient-centric care, even as the Medicare
  medical home demo allows for a concurrent testing
  of one approach

9
Pathway to patient-centric careRevamp the
Medicare Physician Quality Reporting Initiative
(PQRI)

• Mandated by Tax Relief on Health Care Act of 2007
• Transitional program effective July through
  December 2007
• Physicians receive bonus Medicare payments for
  reporting on at least three selected measures
• Legislation also includes framework for selecting
  measures for reporting in 2008 . . . but no money
  is set aside to pay for reporting

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Pathway to patient-centric careRevamp 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

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Pathway to patient-centric careRevamp the
Medicare Physician Quality Reporting Initiative
(PQRI)

• Some specialties have only a few and very basic
  measures that require little or no investment in
  practice-level system improvements
• While primary care physicians have over a dozen
  measures for high impact and prevalent chronic
  illnesses, requiring a greater investment in
  resources to achieve quality gains
• Congress recognized potential inequity by
  requiring only 3 measures be reported per
  physician
• But because measures must be reported for 80 of
  patients to which they apply, primary care
  physicians are likely to see more patients for
  which there will be an applicable measure that
  has to be reported
• 1.5 bonus unlikely to be sufficient

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Pathway to patient-centric careRevamp the
Medicare Physician Quality Reporting Initiative
(PQRI)

• ACP believes Congress should revamp 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

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Example of providing tiered payments for
systems to support patient-centric care

• BTE uses a scoring system that provides higher
  payments for more advanced systems
• Tier 1 the reporting on evidence-based
  standards of care and maintenance of patient
  registries
• Tier 2 the use of electronic systems to
  maintain patient records (EHRs) use of
  clinical-decision support tools the use of
  electronic orders for prescriptions and lab tests
  (e-prescribing), the use of patient reminders
  use of e-consults and managing patients with
  multiple chronic illnesses
• Tier 3 - whether a practices electronic systems
  interconnect and whether they are interoperable
  and can automatically send, receive and integrate
  data such as lab results and medical histories
  from other systems

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MedPAC supports focusing on measures for 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

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Pathway to patient-centric care Provide federal
dollars and office visit add on to support HIT

• Authorize grants, loans, and tax subsidies to
  physicians who acquire HIT and use it for care
  coordination and quality improvement
• Create an add on to Medicare office visit fees
  for specific technologies associated with
  patient-centric care (e.g. registries, clinical
  decision support, secure email)
• The National Health Information Incentives Act of
  2006 included grants and tax incentives plus a
  Medicare office visit add-on (similar legislation
  is expected to be introduced in 110th Congress)

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Pathway to patient-centric careDirect Medicare
to pay for physician-directed care coordination

• Medicare should pay physicians for care
  coordination of patients with multiple chronic
  diseases, instead of pay based solely on volume
  of visits/procedures
• This could be done by creating CPT/HCPCS codes
  and RVUs for care coordination
• Physicians would bill on a fee-for-service basis
  for such codes with documentation of the services
  rendered

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Pathway to patient-centric careDirect Medicare
to pay for physician-directed care coordination

• Examples of possible new codes related to
  patient-centered, longitudinal, coordinated care
  include
• Care plan oversight, for additional specified
  conditions which would include communication with
  other providers offering the patient treatment
• 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

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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

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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

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

• The sustainable growth rate (SGR) cuts payments
  whenever spending exceed per capita GDP
• Since 2002, Congress has replaced annual cuts
  with temporary measures that have only driven up
  the price tag of a permanent solution
• CBO estimates it will cost more than 250 billion
  just to bring annual updates up to inflation
• 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

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

• Congress must repeal the SGR and replace it with
  a framework that
• provides positive updates to all physicians
• allocates a separate pool of dollars to support
  physician-led quality improvement programs that
  offer the greatest potential for quality gains
  and cost savings (e.g. such as higher payments to
  physicians who practice in a qualified PCMH)
• pool of dollars to support physicians quality
  improvements should grow when savings are
  achieved in other parts of Medicare

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

• Medicare should continue to improve the accuracy
  of the Medicare relative value units (RVUs)
• Create a system to identify potentially
  mis-valued services for review by a
  multi-specialty expert process (e.g. the RVS
  Update Committee), based on evidence that work
  has decreased
• Any reductions in RVUs for mis-valued services
  should be redistributed back to the physician
  payment pool
• Review the accuracy of the practice expense RVUs,
  which determine more than 40 of the total
  approved payment per service
• Work with the medicine to assure that advisory
  processes provide balanced representation of
  primary care and physician experts in management
  of chronic diseases

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Pathway to patient-centric careBreak down
Medicare silos and change budget rules to
account for total program savings

• Current Medicare rules do not allow physicians to
  share in savings in other parts of the program
  except as part of Medicare demos
• Congress should direct HHS to create a
  methodology to allow for shared savings resulting
  from care coordination and the PCMH (such as
  preventable hospital admissions)
• Congress should 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, rather than being funded solely through
  redistribution of physician fees
• Congress should 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

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Pathway to patient-centric careSupport state
initiatives to redesign care around a PCMH

• Several states (Missouri, North Carolina,
  Louisiana) have initiated their own programs, or
  applied to the federal government for waivers or
  demonstration project funding, to redesign of
  Medicaid, S-CHIP and other health programs 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

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Pathway to patient-centric careSupport state
initiatives to redesign care around a PCMH

• Congress and CMS should support states by
• Granting or expediting waivers for states that
  wish to redesign financing and delivery around
  the PCMH
• funding demonstration projects to enroll S-CHIP,
  dual eligibles, and Medicaid recipients in PCMHs
  supported by an alternative physician payment
  structure
• providing authority, funding and direction as
  part of the S-CHIP reauthorization bill to states
  that choose to organize care for S-CHIP
  recipients around the PCMH

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Conclusions

• The Medicare medical home demo is an essential
  step that should allow for evaluation of the PCMH
  in multiple sites and practices
• Congress should at the same time pursue other
  pathways to advance patient-centric care
• Such pathways would include revamping Medicare
  pay for reporting, providing funding for HIT,
  paying physicians for care coordination services,
  eliminating the SGR and improving accuracy of
  payments, breaking down the Medicare silos, and
  supporting state initiatives on patient-centered
  care
• The support of the employer community will be
  critical in persuading Congress to pursue
  multiple pathways to advance patient-centric care