Transcript The Medical Home: A Model for Health Reform? February 17, 2009

The Medical Home:
A Model for Health Reform?
February 17, 2009
• James F. Coan
–
Project Officer, Medicare Medical Home Demonstration,
Centers for Medicare & Medicaid Services
• Dr. Chad Boult
–
Professor of Public Health, Director, Lipitz Center for
Integrated Health Care, Department of Health Policy and
Management, Bloomberg School of Public Health, Johns
Hopkins University
• Dr. Barbara Walters
–
Senior Medical Director, Dartmouth-Hitchcock Medical
Center
• Moderator: Laurel Sweeney
–
Sr. Director, Reimbursement & Legislative Affairs, Philips
Healthcare
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MEDICARE MEDICAL HOME
DEMONSTRATION (MMHD):
OVERVIEW
James Coan, Project Officer
Centers for Medicare &
Medicaid Services
Baltimore, MD
2
Authorization


Tax Relief and Health Care Act
(TRHCA) of 2006, Section 204
Medicare Improvements for Patients
and Providers Act (MIPPA) of 2008,
Section 133
3
Specifics
3-Year Demonstration
No more than 8 States
Physician-Based Practices
High-Need Population

Individuals with chronic illnesses that require
regular medical monitoring, advising, or
treatment.

4
Demonstration Design


Reviewed statutes, literature (especially of the American Academy of
Family Physicians (AAFP), American Academy of Pediatrics (AAP),
American College of Physicians (ACP), and American Osteopathic
Association (AOA)), and experiences of others
CMS consulted with ACP, AAFP, and American Geriatrics Society (AGS)
and others

Medicare Medical Home Demonstration design

Physician Practice Connection (PPC-PCMH-CMS)

AMA/Specialty Society Relative Value Scale Update Committee (RUC)
estimated work, office, and professional liability insurance expenses
to establish relative value units (RVU)
5
2 Main Parts of the Medical
Home

The Practice

The Physician
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Medical Home Designation

Medical Home is a term that applies to a
physician-based practice.
• Has necessary capabilities in place
• Practice culture supports Medical Home type
care
• Is committed to coordinating/managing all
patient care
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Tier Structure

Two tiers of medical homes

Tier 1: “Typical” medical home services

Tier 2: “Enhanced” medical home services

Both Tiers are fully functional and qualified
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Tier 1 Requirements

14 required capabilities, for example:
• Discuss with patients the role of the medical home
• Establish written standards for patient access
• Use data to identify/track patients
• Use integrated care plan
• Provide patient education/support
• Track tests/referrals
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Tier 2 Requirements

All Tier 1 requirements

Plus 4 more including;
• Use electronic health record (EHR), certified by the
Certification Commission on Health Information Technology
(CCHIT), to capture clinical information (for example, blood
pressure, lab results, status of preventive services)
10
Practices That Start as Tier 1 Can
Later Apply for Tier 2

Practices that choose to qualify as Tier 1 initially may apply to
qualify as Tier 2 practices in subsequent years
• Complete the PPC-PCMH-CMS
• Provide documentation of Tier 2 capabilities



Upgrade applications accepted during the last 3-months of year 1
and year 2
Additional documentation will reviewed as before
Once Tier 2 qualification is established, the practice can receive the
Tier 2 care management fee
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Which Practices Are Qualified?

Physician-Based practice
• First point of contact and main source of primary care

Must be able to provide medical home services
• Oversee development & implementation of plan of care
• Use evidence-based medicine & decision-support tools
• Use health information technology to monitor & track
health status of patients
• Encourage patient self-management Capabilities qualify
as Tier 1 or Tier 2 as measured by PPC-PCMH-CMS Version
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Participating Physicians



Work within the Medical Home practice
structure
Provide healthcare management services
beyond regular medical care
“Quarterback” of the healthcare
management team
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Which Physicians Are Eligible?

MD/DO board-certified
• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO)
practices providing ambulatory health care, including federally
qualified health centers (FQHCs) and small-, medium-, and largesized practices



Provide first contact, continuous care, main source of primary
care
Eligible: General internist, family practice, geriatrics, some
specialties
Not eligible: Radiology, pathology, anesthesiology, dermatology,
ophthalmology, emergency medicine, chiropractors, psychiatry,
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and surgery
Physician Responsibilities

Each physician in the Medical Home is expected
to provide specific services to each patient as
necessary
• Provide ongoing support, oversight, and guidance
through a health care team
• Provide integrated coherent planning for ongoing
medical care including communication and
coordination with other physicians and healthcare
professionals furnishing care
• Provide development and/or revision of documented
care plans, including integration of new information
and/or adjustment of medical therapy
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Physician Responsibilities
(cont.)
• Track hospital, and other facility admissions, with
appropriate follow-up after discharge
• Oversee and track medication changes initiated by
pharmacy benefit plans
• Provide reconciliation of medications to avoid
interactions or duplications.
• Review medication changes occurring outside of their
own E/M visit, including all prescriptions and related
communication with other physicians and health care
professionals.
• Review reports of patient status from other physicians
or health care professionals
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Physician Responsibilities
(cont.)
• Review results of laboratory and other studies
• Monitor staff to ensure the use of evidence-based
medicine and clinical decision support tools to
facilitate diagnostic test tracking, pre-visit planning,
and after-visit/test follow-up
• Maintain communication (including telephone calls,
secure web sites, etc.) with the patient, family, and
caregivers for purposes of assessment or care
decisions
• Use patient self-management plan (including end-oflife planning, home monitoring)
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Which Patients are
Eligible/Ineligible?

Medicare fee-for-service beneficiaries

At least one eligible chronic condition (86% of beneficiaries)
•

Based on the adapted Hwang et al. list (Health Affairs 2001) on CMS website
At Enrollment:
• Part A and Part B coverage
• Medicare is primary insurance provider

Ineligible:




Medicare Advantage
Hospice
Long-term nursing home
Treatment for end-stage renal disease
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Location and Sample Size

8 sites (A site is a state or a part of a state.)
• Will include urban, rural, medically underserved sites
• CMS announce sites following approval

Sample across all 8 sites (not each site):
• 400 practices (small, med. large, FQHC, RHC, CHC)
• 2,000 physicians
• 400,000 Medicare beneficiaries
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What Are the Benefits to
Practices?

Care management fee

Share in savings

Ability to provide better quality care to patients

Improved practice work flow

Improved job satisfaction
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What Is the Care Management
Fee?



Based on RUC relative value units for physician
work, practice expenses, and professional
liability insurance
In addition to activities already reimbursed by
Medicare
Risk-adjusted, based on hierarchical condition
categories (HCC) score of the patient
21
What Is the Care Management
Fee?
Per Member Per Month Payments
Patients
Patients
Medical
with HCC
with HCC
Blended
Home Tier
Score <1.6 Score ≥1.6
Rate
1
2
$27.12
$35.48
$80.25
$100.35
$40.40
$51.70
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Next Steps

Recruitment
• Notify all practices in demo sites

Application
• Submission of initial application

Qualification
• PPC-PCMH-CMS

Beneficiary Enrollment
• Beneficiary education and agreement
23
Additional
Information/Questions
James F. Coan, Project Officer
www.cmsmedicalhome.org
[email protected]
24
Technical Assistance
for the Medicare Medical Home
Demonstration Project
Dr. Chad Boult
Johns Hopkins Bloomberg School of Public Health
February 17, 2009
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Technical Assistance
•
•
•
•
•
•
•
•
Guided Care implementation manual
On-line course for Guided Care nurses
On-line course for physicians
Guidance in selecting HIT
Online practice self-assessment (“MHIQ”)
Webinars, learning collaboratives, networks
Information by Internet and telephone
Consultation
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Pay for Performance at DH
“Your Medical Home”
Barbara Walters DO, MBA
Senior Medical Director
Dartmouth - Hitchcock
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Dartmouth-Hitchcock
• Dartmouth- Hitchcock
clinic
•Mary Hitchcock
Memorial Hospital
•Dartmouth Medical
School
•VA Medical Center in
White River Junction
•Dartmouth-Hitchcock
Alliance
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Dartmouth-Hitchcock Operations







1,500,000 outpatient
visits per year
21,000 inpatients
1000+ physicians
7500 employees
900+ medical
students, residents &
fellows
Reimbursement
environment – All FFS
EMR’s & data
warehouse
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CMS Physician Group Practice
Demonstration Project
The
Pre-work ?
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CMS Demonstration Project





10 multispecialty groups
FFS Medicare Environment
Assignment of patients
done retrospectively based
on preponderance of care
Responsibility for total cost
of care
Bonus allocated for cost
savings first – then quality
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CMS Results




We achieved savings in
year 1 , but did not meet
the threshold for bonus
payment
We achieved all quality
metrics in year one
We achieved savings and
passed the threshold in
year 2, so received 6.8
million dollars of bonus
payouts
We achieved 98% of the
quality metrics , so part of
the above payout was for
quality
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Most Important Clinical
Interventions
ICD 9 Coding Training
 Transform the role of the RN – health
coaches, and pre-visit planning
 Registry Development
 Post Discharge Phone Call

33
Where did we see a difference?




Our risk adjusted total cost
was lower than the
comparison group – we
had significantly sicker
patients who we cared for
more efficiently
Our admission rate for all
of our patients was lower
than our comparison group
The cost of care of our CHF
patients was less than out
comparison group
Our quality was better
than the comparison group
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Cigna Project

The CMS project
was successful so
we began looking
for a Commercial
plan to partner
with to apply our
clinical model to
that population
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Improve on the CMS model

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


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Attribution was for primary care providers only
First dollar savings
Quality metrics for clinical conditions in control of
the primary care dept.
Ongoing payment for care management – biggest
issue for implementation!
Bonus methodology needs to include employer
groups – especially self-funded, so most of the
practice ‘s patients are included..
Create a preferred environment for primary care
doctors to practice
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Commercial Plans Additional
Concerns



Access-Access-Access
– ER usage still high
– Gaps in care , especially
for preventative visits
Employer Groups and selffunded plans need early
results to sign on
Health plans have disease
management initiatives –
how to collaborate?
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Design and Negotiate the Pilot
38
Adopted the Joint Principles for
Medical Home Designation
 Personal Physician
 Physician directed medical practice
 Whole person orientation
 Care is coordinated and/or integrated
 Quality and safety are hallmarks
 Enhanced access
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Adopted Reimbursement
Principles
Reimbursement should

Reflect the value of non-face time

Pay for care coordination

Support adoption and use of HIT for QI

Support enhanced communication such as secure email and
telephone consultation

Allow for separate fee-for-service visit payment

Recognize case mix differences in patient population

Allow for physicians to share in savings from reduced
hospitalizations

Allow for additional payments for achieving measureable
quality improvements
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NCQA PPC-PCMH
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NCQA PPC-PCMH
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Patient Centered Medical Home Bonus Model
Assess Bonus Eligibility
quality assessment greater than or equal
to market average
Provide analysis
with rationale for
no bonus
Does practice
meet criteria?
No
No
Yes
compare medical
cost trend to
market, must beat
market tmc trend
Does practice
meet criteria?
Bonus Pool Funding
Savings minus X% of
care coordination fee
Pool Split Employer
Yes
X% PCMH-potential
of Y%
MH Quality pool
maximum 2/3 of bonus
pool distribution
based on degree of
meeting EBM
measures
Apply Payment cap Compare total paid to
the PCMH - any amount
above the cap goes to
the customer, amounts
below will go to the
PCMH
End
PCMH Pool Split
MH Cost Pool
1/3 of bonus pool
distribute 100%
include analysis for
bonus
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Results to date

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
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Began 4-1-09
Data clean up – our docs?, our patients?
Steering Committee and Operational Committee
structure
Received Baseline performance year data
– Working on gaps in care
– Identifying patients who need case
management
Continue enhancing the Medical Home Practice
Model in each of our 48 sites
GREAT collaboration !! – too early for results
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Questions
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Tell us what you think…
Please go to http://www.tinyurl.com/philips217
to complete a quick survey on this session.
If you have suggestions for new webinars,
please note them on the survey.
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Jim Coan
Social Science Research Analyst
Office of Research Development and Information
Centers for Medicare and Medicaid Demonstrations
Jim Coan is a Social Science Research Analyst in the Demonstrations Program Group of the Office of
Research Development and Information in the Centers for Medicare and Medicaid Services. The
majority of Jim’s experience, however, comes from the world of public health as a Senior Public Health
Advisor for 22 years with the Centers for Disease Control and Prevention. During that time Jim has
worked extensively in the areas of communicable disease prevention, vaccine preventable diseases,
and chronic disease prevention at the local, state, and national levels. He also has worked abroad in
Southeast Asia with Indochinese refugees.
Throughout his career, Jim has developed an extensive background in research design methodologies
and coverage and payment systems, as well as in social marketing and health promotion and disease
prevention approaches. Jim came to CMS in 1995 and now devotes his skills and experience to
conducting research demonstration projects for Medicare and Medicaid populations. Jim is the Project
Officer for the Medicare Medical Home Demonstration Project.
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Chad Boult, MD, MPH, MBA
Eugene and Mildred Lipitz Professor
Director of the Roger C. Lipitz Center for Integrated Health Care
Department of Health Policy and Management
Johns Hopkins Bloomberg School of Public Health
Dr. Chad Boult is the Eugene and Mildred Lipitz Professor of Health Policy and Management at the Johns Hopkins Bloomberg
School of Public Health. He directs the Roger C. Lipitz Center for Integrated Health Care and holds joint appointments on the
faculties of the Johns Hopkins University Schools of Medicine and Nursing. The mission of the Lipitz Center is to improve the
health and quality of life for people with complex health care needs by conducting research and disseminating new knowledge. The
Center is also committed to preparing the next generation of leaders in this field. Dr. Boult advises multiple masters, doctoral, and
post-doctoral students and teaches two graduate-level courses: “Innovations in Health Care for Aging Populations,” and
“New Frontiers in Gerontology.”
A geriatrician for more than 17 years, he has extensive experience in developing, testing, evaluating, and diffusing new models of
health care for older persons. His current research includes Guided Care, a novel, multi-disciplinary model of primary care for older
people with multiple chronic conditions. Guided Care is designed to improve the quality and outcomes of complex health care by
improving the delivery system’s design, decision support, access to clinical information, support for self-management, and by
facilitating patients’ access to community services. Dr. Boult is the Principal Investigator of a multi-site, cluster-randomized controlled
trial of Guided Care involving 48 physicians, 933 older patients, and 319 family members in the Baltimore-Washington DC area. The
study is funded by a public-private partnership of the Agency for Healthcare Research and Quality, the National Institute on Aging,
the John A. Hartford Foundation, and the Jacob and Valeria Langeloth Foundation.
As an expert on chronic care, Dr. Boult has spoken at meetings and conferences throughout the world. He has published projections
of the number of disabled older Americans in the 21st century and numerous studies of the outcomes of innovative models of health
care for older persons. He created the first validated instrument for identifying high-risk older persons (the Pra) and co-edited a book
entitled “New Ways to Care for Older People: Building Systems Based on Evidence: Springer Publishing Company, 1999.” He
received the Excellence in Research Award from the American Geriatrics Society in 2000. From 2000-2005 he edited the “Models
and Systems of Geriatric Care” Section of the Journal of the American Geriatrics Society. He has reviewed manuscripts submitted to
many scientific journals and grant proposals submitted to the National Institute on Aging, the Agency for Healthcare Research and
Quality, and several foundations. When time allows, he provides consultation to health care organizations that seek to improve
health care for persons with chronic conditions. Additional information is available at www.jhsph.edu/LipitzCenter and
www.GuidedCare.org
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Barbara A. Walters, D.O., M.B.A.
Senior Medical Director
Southern NH Community Group Practices
Dartmouth-Hitchcock
603-629-1101
[email protected]
Dr. Barbara Walters, Senior Medical Director for Dartmouth-Hitchcock’s Southern New Hampshire
Community Group Practices, is responsible for management of ambulatory practice operations located
in 15 locations, employing 1,200 employees, 300 providers, and providing 1,000,000 visits per year. In
addition she is responsible for commercial payor contracting for the Dartmouth-Hitchcock system and is
the principal investigator for the CMS PGP Demonstration Project. Board certified in psychiatry and
neurology, Dr. Walters came to Dartmouth-Hitchcock in 1998 from the Carolina Permanente Medical
Group in Chapel Hill, North Carolina, with extensive experience in group practice and managed care.
She earned her medical degree from Michigan State University, completed her internship in Family
Practice at Lansing General Hospital in Lansing, Michigan, and her psychiatric residency at the
University of North Carolina, Chapel Hill. Dr. Walters received her M.B.A. degree from Duke University
in 1998.
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