Transcript Crisp White & Navy - University of New England

Maine Multi-Payer Pilot
Patient Centered Medical Home Model
A Collaborative Effort of
the Maine Quality Forum, Quality Counts, &
the Maine Health Management Coalition
Lisa M. Letourneau MD, MPH
November 2008
Objectives
• Review history, principles of Patient
Centered Medical Home model
• Describe development, goals for Maine
Multi-payor Pilot of PCMH model
• Outline key steps for successful PCMH
pilot implementation in Maine
The Challlenge
The Facts
More (and more) U.S. health care spending…
Why Not the Best? Results from the National
Scorecard on U.S. Health System Performance 2008,
Commonwealth Fund
Does not equal better outcomes (and sometimes worse)
The Facts
More primary care services are associated with better outcomes
better------Primary care score ranking------- worse
Healthcare Outcomes
Rank*
0
1
2
3
4
5
6
7
8
9
10
11
12
0
1
2
3
NTH/DK
4
5
6
7
8
9
SP
UK
FIN
SWE
CAN
AUS
BEL
GER
United
States
10
*Rank based on patient satisfaction, expenditures per person, 14 health indicators, and
medications per person in Australia, Belgium, Canada, Denmark, Finland, Germany,
Netherlands, Spain, Sweden, United Kingdom, United States
Defining Primary Care
“The provision of integrated, accessible health
care services by clinicians who are
accountable for addressing the large majority
of personal health care needs, developing a
sustained partnership with patients, and
practicing in the context of family and
community.”
Institute of Medicine: Primary Care: America’s Health in a New Era,
Washington DC: National Academy Press, 1996
What We Want from Primary Care
• A relationship with our providers that
crosses settings, time, & place
• Caring, compassionate interactions
• Coordination & integration of care
across providers
• Ability to access care 24/7 – when &
where we need it
• Time, time, time…
What Do We Get?
The 15 minute visit!
Why? Follow the Money!
Vs.
What we want:
• Relationship with our
providers
• Caring, compassionate
interactions
• Coordination &
integration of care
• Ability to access care
24/7
• Time, time, time…
What we pay for:
• Visits
• Tests
• Procedures
• Procedures
• Procedures
The Stalemate that Blocks Change
Providers unable to
transform practice without
viable & sustainable
payment for desired
services
B
U
T
Employers & payers
unwilling to pay for desired
services unless primary
care demonstrates value
AND create potential to
save money
The Result: The Current Primary Care Home
The Medical Home:
A Model for Change!
Providers transform
practice, create value with
viable & sustainable
payment for desired
services
= Practice Transformation
A
N
D
Employers & payers pay
for desired services
because primary care
demonstrates value AND
saves money
= Payment Reform
Breaking the Stalemate
PCMH recognizes need, supports BOTH…
Practice Transformation
+
to give us what we want…
• Relationship with our
providers
• Caring, compassionate
interactions
• Coordination & integration
of care
• Ability to access care 24/7
Payment Reform
to pay providers for …
• Time for caring,
compassionate
interactions
• Coordination & integration
of care, care management
• Access to care 24/7
• Information systems
needed to integrate care
• Population health
management
Defining Medical Home
“A medical home is not a building, house, or
hospital, but rather an approach to providing
comprehensive primary care. A medical
home is defined as primary care that is
accessible, continuous, comprehensive,
family centered, coordinated, compassionate,
and culturally effective.”
American Academy Pediatrics
Medical Home - Background
• Concept first introduced by AAP in 1964 –
children with special health care needs
• AAFP “New Model” of family medicine – 2004
• Tested in “National Demonstration Project”
(TransforMED) - 2006-2008
• AAP, ACP, AAFP, AOA together draft
“PCMH Joint Principles” - 2007
• Partner with health plans, employers, CMS in
“Patient Centered Primary Care Collaborative”
• Emergence of multi-stakeholder pilots across
country
AAFP-AAP-ACP-AOA
PCMH Joint Principles
1. Every patient has a personal physician
2. Care is provided by a physician-directed
team who collectively care for patient
3. Personal physician is responsible for
providing all patient’s needs, or arranging
for services to be provided by others
4. Care is coordinated and integrated across
all aspects of healthcare system
AAFP-AAP-ACP-AOA
PCMH Joint Principles
5. Quality and safety are hallmarks of PCMH


Evidence-based guidelines and tools guide care
Practice regularly assess its quality of care
6. Patients are offered enhanced access to
care (e.g. expanded hours, enhanced
communication options)
7. Payment appropriate recognizes added
value of PCMH
PCMH-Emergence of Multi-Payer Pilots
RI
Multi-Payer pilot discussions/activity
Identified pilot activity
No identified pilot activity
Maine PCMH Pilot Leadership
Maine
Quality
Forum
Quality
Counts
Maine Health
Management
Coalition
Maine Multi-Payer PCMH Pilot
• Led by neutral multi-stakeholder collaborative –
MQF, QC, MHMC, open to all interested
• Participation of 4 major private payers & MaineCare
• Established mission & vision, guiding principles for
Maine PCMH model
• Pending funding resources…,
– Will select 10-20 pilot practices across state
– Will provide shared resources to support practice
transformation
– Will develop framework to promote shared learning
across & beyond pilot practices
Maine Multi-Payer Pilot Status
PCMH Working Group – work to date:
1. Secured initial funds for planning process
2. Est’d Maine PCMH model thru mission &
vision, Maine PCMH Guiding Principles
3. Est’d criteria, threshold for practice site
participation
3. Dev’d initial framework for pilot evaluation
4. Dev’ing specific expectations practice
participation (MOA)
5. Dev’ing criteria, method for selecting
practice pilots
Maine Multi-Payer Pilot Status
PCMH Working Group – work in progress…
6. More fully identify outcome measures,
evaluation plan
7. Dev plan for supporting practice
transformation
8. Conduct outreach, communication to key
stakeholders, including all PCP practices
9. Identify additional resources to support
implementation
Maine Multi-Payer – Payment Model
MHMC-convened Physician Payment Reform Comm
• Dev’d principles for payment model
• Has kept all private payers & MaineCare at table
• Proposed (9/24) 3-component payment model



Prospective (pmpm) care management payment
Ongoing FFS payments, possibly with additional
payments for previously non-reimbursed services
Performance Payment for meeting quality & total
cost savings targets – shared savings model
Maine PCMH Pilot:
What Practices Need to Know
• Criteria for application
– Maine primary care practice
– Completed MHIQ c/w Level I NCQA PPC-PCMH
– Minimum panel size (TBD)
• Agreements for participating practices (MOA)
– Identified leadership, full participation of practice team
– Participation in PCMH Learning Collaborative, QI
coaching
– Tracking, submission of clinical outcomes data
– Agreement to achieve “Core Commitments” within 12
mos of start
Maine PCMH Pilot
Practice “Core Commitments”
(DRAFT!)
1.
2.
3.
4.
5.
6.
7.
8.
Demonstrated physician leadership
Team-based approach
Practice-integrated care management
Same-day access
Behavioral-physical health integration
Inclusion of patients & families
Connection to community / local HMP
Commitment to waste reduction
PCMH & Opportunities for
Improving Safe Prescribing
• Medical home as focal point for
coordinating prescribing across
providers
• EMR / registry support
• Nurse care coordination
• PCMH Learning Collaborative to offer
support on safe prescribing
• Ultimately… TIME!!
Maine Pilot - Issues TBD
• Will all employers, payers engage in new
payment model?
• Will new payment be enough to support
true practice transformation?
• What criteria for pilot site selection?
• How to engage specialists, hospitals in
shared goals, shared cost savings?
• How to engage patients in new partnership?
Needed to Move Forward
• Engagement, leadership, and dialog among
key stakeholders
– Consumers
– Physicians, NPs, provider organizations/PHO’s,
medical groups
– Payers – private & public
– Employers
– Public health
• Culture change to create, sustain
transformative change
• Commitment to collaboration!
PCMH
Creating Hope for a Better System
With thanks to Dr. Tom Bodenheimer, Dept. Family & Community Med, UCSF