Transcript Slide 1

The Patient-Centered
Medical Home:
Overview, Outlook & Trends
FEBRUARY 20, 2009
Elizabeth E. Stewart, PhD
Center for Research in Primary Care & Family Medicine
TransforMED
What a Medical Home is NOT
Meet Rebecca…
Working
Mother.
Today she woke up with a
fever and UTI symptoms.
She needs to juggle work
coverage, child care and
household responsibilities
along with her immediate
healthcare problem.
What a Medical Home is NOT
Difficulty in
scheduling appt
for that day.
No alternative
way to seek
treatment from
practice.
Staff sounded
harried; had
trouble locating
her records
Hours at practice
were limited so
Rebecca had to
arrange to leave
work.
What a Medical Home is NOT
Waited for
almost an hour;
staff still had
not found her
records.
Did not see her
own physician
and repeated the
same information
to multiple people.
Physician was
rushed; Rebecca
was too timid to
ask about strange
pain in her breast.
When Rebecca tried to
make a follow-up
appointment for full
physical, the wait time
would be 4 months.
Slide courtesy of
www.pcpcc.net
Primary Care Crisis
Good evidence that primary care that countries
with strong primary care infrastructures have
lower costs and better outcomes.1
In the US, fewer and fewer graduates are
choosing primary care:
* Shrinking reimbursements
* Increasing demands
* Overall lack of respect.
A recent study revealed 49% of PCP’s said
they plan to cut back or retire in 3 years.2
Enter: The Medical Home
• In 1967, The American
Academy of Pediatrics
introduced the term to describe
a single source of medical
information and coordination for
sick children.3
• Over the next 40 years, many
other organizations endorsed
the concept and the term.4
Medical Home Core Features
• In 2007, four major medical organizations
(AAFP, AAP, ACP, AOA) reached
agreement on “Joint Features of the
Patient-Centered Medical Home.” 5
• In 2008, the AMA gave their endorsement.6
Medical Home 7 Core Features
1. Person Physician
Each patient has an
ongoing relationship
with a personal
physician trained to
provide first contact,
continuous, and
comprehensive care.
Medical Home Core Features
2. Physician directed
medical practice – the
personal physician leads
a team of individuals at
the practice level who
collectively take
responsibility for the
ongoing care of patients
Medical Home Core Features
3. Whole person orientation
The personal physician is
responsible for providing for
all the patient’s health care
needs or taking responsibility
for appropriately arranging
care with other qualified
professionals.
Medical Home Core Features
4. Care is coordinated and/or
integrated across all
elements of the complex
health care system, making
sure patients get the
indicated care when and
where they need and want it.
Medical Home Core Features
5. Quality & Safety are Hallmarks:
•
•
•
•
Decisions are made by EBM and appropriate
decision support tools
Information Technology is used appopriately
Patients participate in decision making
Patient feedback is actively sought to ensure
expectations are met.
Medical Home Core Features
6. Enhanced access to
care is available
through systems such
as open scheduling,
expanded hours and
new options for
communication.
Medical Home Core Features
7. Payment appropriately recognizes the
added value provided to patients who have
a patient-centered medical home.
• Reflect the value of physician and non-physician staff
patient-centered care management
• Should pay for services associated with coordination of
care both within a given practice and between consultants,
ancillary providers, and community resources.
Testing the Feasibility
of the Medical Home
The Future of Family Medicine:
“Ultimately, system wide changes
will be needed to ensure highquality health care for all
Americans. Such changes include
taking steps to ensure that every
American has a personal
medical home…” 7
2006
www.transformed.com
Practice Management
• Disciplined financial management
• Cost-Benefit decision-making
• Revenue enhancement
• Optimized coding & billing
• Personnel/HR management
• Facilities management
• Optimized office design/redesign
• Change management
Access to Care & Information
• Health care for all
• Same-day appointments
• After-hours access coverage
• Lab results highly accessible
• Online patient services
• e-Visits
• Group visits
Practice Services
Health Information Technology
• Comprehensive care
for both acute and chronic conditions
• Electronic medical record
• Prevention screening and services
• Electronic prescribing
• Surgical procedures
• Evidence-based decision support
• Ancillary therapeutic & support services
• Population management registry
• Electronic orders and reporting
• Practice Web site
• Ancillary diagnostic services
• Patient portal
Care Management
Quality and Safety
• Population management
• Evidence-based best practices
• Wellness promotion
• Medication management
• Disease prevention
• Patient satisfaction feedback
• Chronic disease management
• Clinical outcomes analysis
• Care coordination
• Quality improvement
• Patient engagement and education
• Risk management
• Leverages automated technologies
• Regulatory compliance
Continuity of Care Services
• Community-based services
Practice-Based Care Team
• Collaborative relationships
Hospital care
Behavioral health care
• Shared mission and vision
Maternity care
Specialist care
• Provider leadership
• Effective communication
• Task designation by skill set
• Nurse Practitioner / Physician Assistant
Pharmacy
• Patient participation
Physical Therapy
• Family involvement options
Case Management
Medical Home: Is it possible?
Early data point to a cautiously
optimistic “YES” but…
- Two years is not enough.
- Transformation process is far
greater challenge than previously
anticipated.
- Many lessons to be learned
from real life application.8
Will it save money & improve
outcomes?
• Getting the attention of payers & politicians
• > 25 multi-stakeholder projects are
underway in 22 states, most with formal
evaluations.
• Growing interest in the formation of state
MH demonstration projects; use of term in
crafting legislation.9
Community Care of North Carolina
•Since 1999, the state has invested in many MH
components through disease management
payments to practices with Medicaid pts.
• Emphasis on physician led team approach, disease
tracking & care managers within practices.
•Significant improvements in cost, utilization, and
quality measures. Two major evaluations estimate it
CNCC saved the state between $230 and $260
million in 2004.12
MH Outlook: Pilots & Payers
• PCPCC is a coalition of >300 organizations:
employers, consumer groups, patient advocates, etc
• Collaboration of like-minded stakeholders actively
working toward medical home vision.
• Comprehensive list of pilot projects: www.pcpcc.net
MH Outlook: Accreditation
• National Committee for Quality Assurance
offers 3 tiers of “medical home recognition”
• Practices are hopeful that such recognition will
lead to higher reimbursement by public and
private payers… such recognition is a required
part of many ongoing and future pilots.
PCMH Outlook: CMS Demonstration
CMS preparing to launch 2-year Medicare
Medical Home Demonstration (MMHD).
Looking at impact of medical home on:
- Medicare cost
- Utilization
- Health outcomes
- Patients
- Physicians & Practices
PCMH Outlook: CMS Demonstration
•Practices must meet criteria of NCQA to qualify
(Tier 2 and Tier 3 only)
•Qualified practices receive additional care
management fees based on RUC work RVUs,
practice expenses, and insurance.
• MMHD link on CMS website:
http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp
PCMH Outlook:
Gaining Political Traction
New economic stimulus
bill earmarks ≈ $19 billion
to implement electronic
medical records and other
health information
technology.13
PCMH Outlook: Gaining Political Traction
Senator Baucus (D-Montana) white
paper on health care reform
endorsed medical home concept,
even suggesting that specialists
may see a small cut in
reimbursements in order to pay
primary care physicians for
currently non-reimbursable
coordination services.14
PCMH Outlook: Gaining Public Traction
Medical Home: Challenges
• Transformative change doesn’t happen
overnight… pilots under pressure for quick
results may do more harm than good.
• Simply inserting HIT is not the solution.
• Primary care physicians have mixed
responses to the concept.
Medical Home: Physician Outlook
• Excited
• Cautiously optimistic
• Skeptical/cynical
• Too exhausted &
stressed to care
Medical Home: Physician Outlook
• Financially-strapped FM physicians are fearful
of the high cost of MH changes (time,
resources, equipment) without a guarantee of
increased reimbursement.
• Like many researchers/policy makers, they
are concerned about short time frame of
current pilot projects given enormity of
necessary changes.
“…some health care policy experts
"worry that the push for medical homes
could be yet another example of the
latest health care fad -- quickly
embraced by employers desperate to
slow their soaring health costs, and just
as quickly forgotten when they do not
provide immediate results.” 15
Medical Home: Outlook
“I no longer practice medicine
encounter to encounter, taking
care of the problem the patient
presents with. I take care of them
in between visits online, plus I
use each visit as an opportunity
to improve their overall health,
addressing any overdue health
maintenance or disease mgt with
the help of my nurses…”
Dr. Susan Andrews
Nat’l Demonstration Project
Family Practice Partners
Murfreesboro, TN
Medical Home: Outlook
“I do take care of my patients how
and when they want to be seen as
much as I can, whether it is in the
office, online, or by phone and
letter… I love my job. I look forward
to working with my staff each day. It
is a real pleasure seeing a nurse or
MA, a receptionist, or an office
manager stretch herself and grow. I
treasure my interactions with each
and every patient.” 16
Dr. Susan Andrews
Family Practice Partners
Murfreesboro, TN
Medical Home: Outlook
• We know that a strong primary care
system reduces health care costs and
improves quality outcomes. 17
• We know that primary care doctors feel
underpaid and demoralized and their labor
forces is shrinking. 18
Medical Home: Outlook
• We know that the majority of primary care
physicians would like to embrace the medical
home concept… and those that have, cite
greater satisfaction with their jobs.19
• Finally, we know that the evidence for a
medical home is being created right now... but
true change takes time, and so do results.
Medical Home: Trends
From the ground level:
What seems to be
working for physicians,
practices and patients?
PCMH
Trends:
Same Day
Scheduling:
Patients can
schedule an appt
for the same day
OR in advance
PCMH Trends: Same Day Scheduling
• Huge leap of faith for many physicians
fearful of an open schedule.
• Once in place, overwhelmingly positive
response from physicians and patients.
• Requires an understanding of the
supply/demand cycle by day, week,
season.20
Trends: Same Day Scheduling
• Requires constant education of patients
using multiple channels.
• Some patients prefer the option to
schedule ahead.
• $$ saved – drops in no-show rates, less
staff time on reminder calls.21
PCMH Trends:
e-Visits:
Physicians offer
structured, secure
“office visits”
online
PCMH Trends: e-visits
• Only lukewarm response from patients; takes
concerted & consistent promotion by practice
• Many e-visit modules do not interface with
EMRS requiring extra work for documentation
• Currently, limited reimbursement by payers23
PCMH Trends: e-visits
• Currently, patients seem to prefer non-secure, nonreimbursable email communication with physicians in
lieu of phone calls.
• Physicians acknowledge time saving by email vs.
multiple phone calls.
• Potential to be popular with certain pt populations.24
PCMH Trends: Group Visits
• Typically centered around a
chronic disease; goal is for
physician to facilitate peer-topeer learning.
• Evidence that group visits
can result in improved health
outcomes & increased pt
compliance. 25
PCMH Trends: Group Visits
• Require paradigm shift from physicians: solo
encounter to group facilitation process.
• Require tremendous planning and preparation
work up-front; difficult without extra staff.
• Concerns about reimbursement & coding.
• Patients often reluctant to attend; then report
increased satisfaction after visit.26
Population Management
Chronic Disease
Management
Disease Prevention
PCMH Trends:
Disease
Registries
PCMH Trends: Disease Registries
• Practice runs report on all
diabetics overdue for a follow-up
visit or out of compliance.
•Pts are called or emailed to set up
an appt and get lab work.
• During appt, EBM point-of-care
reminders guide staff to arrange
additional care (e.g., flu shot,
mammogram).
PCMH Trends: Disease Registries
• Many EMRs do not yet offer disease registry
capabilities OR process is difficult to establish.
• Many stand-alone disease registries do not interface
with EMRs, requiring double data entry.
• Requires paradigm shift: from acute, one-on-one
episodic care to proactive management of a
population of patients. 27
PCMH Trends: Care Teams
Care teams
usually consist of
a physician and 1
or 2 support staff
who take on
increased
responsibility of
patient care.
MA/RN does vital signs,
medications, history,
standing orders, etc
Doctor completes exam &
talks with pt; MA in room
might document on EMR
during exam
PCMH Trends: Care Teams
Care teams
require increased
staff training and
allocation of
resources up
front; willingness
of physician to
delegate.28
MA/RN does follow-up
education wit pt & followup coordination of care
(scheduling labs, etc)
Doctor goes to next
pt with no downtime
PCMH Trends: Care Teams
• Evidence of increase in
- Pt volume & revenue
- Quality of care
- Doctor/staff satisfaction29
• Challenges:
- Upfront allocation of
resources w/out immediate
pay-off
- Qualified staff cost more
PCMH Trends: Patient Portals
• Interactive patient portals
interfaced with practice EMR
• Pts can schedule appts, refill
medication, send in BP or
blood sugar results, etc
• Pts can view all or parts of their
chart, lab work, test results, etc
PCMH Trends: Patient Portals
• Allows patient greater
participation in their care
• Physicians note that having
charts online can be “humbling”
but helpful to increasing pt
engagement
• Online services can save
practice staff time & calls
PCMH Trends: Patient Portals
CHALLENGES:
• Portals cost money to implement & maintain but
most pts are not willing to pay extra for services
• Some pts are not web-enabled
• Takes additional Dr/staff time upfront to train pts
to use portal and redesign workflow processes
(e.g. how to return lab results). 30
Greatest PCMH Promises:
 Quality of care
 Overall costs
 Satisfaction
* patients
* families
* physicians * staff
Greatest PCMH Challenges:
• Transformation of a practice takes
incredible time, energy & resources.
• Currently, majority of implementation &
refinement of PCMH is non-reimbursable.
• Engagement and education of patients –
their role in the PCMH is also different.31
What a Medical Home IS
Meet Rebecca…
Working
Mother.
Today she woke up with a
fever and UTI symptoms.
She needs to juggle work
coverage, child care and
household responsibilities
along with her immediate
healthcare problem.
What a Medical Home IS
She was able to make her appt that day
before 8am by using online scheduling.
She was in & out of the office in <45 min.
The disease registry reminded the MA of
overdue health maintenance services.
Rebecca could later check her lab results
online without playing phone tag.
Rebecca felt warm & welcomed at her PCMH.
Thank you.
Elizabeth E. Stewart, PhD
[email protected]