THE COMMONWEALTH

FUND

Melinda Abrams, MSThe Commonwealth Fund

Patient-Centered Primary Care CollaborativeCenter for Multi-Stakeholder Demonstrations

February 23, 2009

www.commonwealthfund.org

Patient-Centered Medical Home: Overview of Commonwealth Fund-Supported Evaluations

Commonwealth Fund Commission on a High Performance Health System

Established in July 2005

Chairman: James J. Mongan, MD, President and CEO, Partners HealthCare System, Inc. (Boston, MA)

Objective: To chart a course for a U.S. health care system that

provides significantly expanded access, higher quality, and greater

efficiency for all Americans.

How Do We Want Health Care To Be Organized and Delivered?

6 Attributions

1. Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic health record systems.

2. Patient care is coordinated among multiple providers and transitions across settings are actively managed

3. Providers (including nurses and other members of the care team) both within and across settings have accountability to one another, review one another’s work, and collaborate to reliably deliver high-quality, high-value care.

4. Patients have easy access to appropriate care and information, including after hours; there are multiple points of entry to the system; and providers are culturally competent and responsive to patients needs.

5. There is clear accountability for the total care of the patient

6. The system is continuously innovating and learning in order to improve the quality, value, and patients’ experiences of health care delivery.

Source: Organizing the U.S. Healthcare System for High Performance (August 2008). The Commonwealth Fund Commission on a High Performance Health System.

Getting the Care We Want: Policy Recommendations from the Commission

1. Payment reform

2. Patient incentives

3. Regulatory changes

4. Accreditation

5. Provider training

6. Government infrastructure support

7. Health information technologySource: Organizing the U.S. Healthcare System for High Performance (August 2008). The Commonwealth Fund Commission on a High Performance Health System.

Why Are Evaluations of PCMH Demonstrations Important?

• Considerable information suggests the patient-centered medical home will result in better quality, improved patient experience and greater efficiency

• However, gaps in the evidence exist

• Need to rigorously evaluate demonstrations to improve health care and health policy

• Need information that is useful to policymakers, purchasers, payers, clinicians and patients

• (How many evaluations do we need?)

PCMH Evaluations: Key Research Questions

• Do physician offices that receive technical assistance and revised payment structure improve their performance on measures of clinical quality, patient experience and efficiency?

– Are physician practices able to make the changes necessary to function as patient-centered medical homes? What “worked”?

• Is care in PCMHs of higher quality than in non-PCMHs?

• Are patients’ experience better in PCMHs than non-PCMHs?

• Do PCMHs help slow the rate of health care cost growth?

• Do PCMHs help lower health care costs? (Or, lower costs for high-cost groups of patients?)

• Do PCMHs help reduce racial/ethnic disparities?

• Do physicians/staff in PCMHs report higher job satisfaction than their colleagues practicing in non-PCMH practices?

• Does the degree a practice embrace PCMH principles correlate with improvement (clinical, PE, MD satisfaction)?

Marshal Chin, MDUniversity of Chicago

Judith Fifield, PhDUniversity of Connecticut

Meredith Rosenthal, PhD Harvard School of Public Health

Diane Rittenhouse, MD, MPH

University of California, San Francisco

Carlos Jaén, MD, PhD

University of Texas Health Science Center

NOLA

Additional Evaluations Recently Approved (November 2008)

Lisa Kern, MD, MPH

Weill Cornell Medical Center

David Bates, MD, MSc.

Brigham and Women’s Hospital

Meredith Rosenthal, PhD

Harvard School of Public Health

MA -CPR

Comparison of Demonstrations (1)

# practices19

(28 sites)5 70 9 22-30

# of MDs 71 28 250 90 ~100

# of payers 1 4 6 1-5?7 (CO)

3+ (OH)

# of

patients27,000 28,000 1 million 100,000 60,000

Payment model

P4P

FFS

PMPM

FFS

PMPMP4P

Annual, comprehensive

PC fee

P4P

FFS

PMPM

CO

OH

MA -CPR

# of clinics 5025 practices

(67 sites)

# of MDs TBD 150

# of beneficiaries TBD 103,000

# of payers 0 1

Payment Method N/A

P4P (quality)

Federal grant program

(increased access)

Comparison of Demonstrations (1) (continued)

NOLA

Comparison of Demonstrations (2)

Pediatric practices? Pedia-tricians?

X X XCO – Y

OH – NX X

Safety net clinics included?

X X X XCO – Y

OH – NX X

State Medicaid as payer?

X X MaybeCO – Y

OH – N

NOLACO

OH

MA -CPR

Comparison of Research Questions (1)

Do PCMHs improve . . .

Clinical Quality?

X X X X X X

Patient Experience

X X X X X X X

Efficiency? X X X X X X X

MD/ Staff experience

X X X X X X

NOLACO

OH

MA -CPR

Comparison of Research Questions (2)

Practices

effectively transform?

X X X X X X X

Practices financially stable?

X X

What are costs to practice?

X

CO

OH

NOLAMA -CPR

Comparison of Measures

Office Systems

NCQA PCMH

NCQA PMCH

NCQA PCMH

NCQA PCMH

NCQA PCMH

Clinical Quality

HEDIS, PQRI

HEDIS, PQRI

10 HEDIS measures

AQA, HEDIS, 3

chronic dz

HEDIS, PQRI

Patient Experience

Modified CAHPS

Modified CAHPS

Modified CAHPS

Modified CAHPS

Modified CAHPS

Cost

Claims analysis:

Comparison of projected

versus actual costs

Claims analysis: Changes in utilization and expenditures

Claims analysis:

Utilization and ETGs

Claims analysis:

Changes in utilization and expenditures

Same as Rhode Island

CO

OH

MA -CPR

Challenges/ Concerns

• Complex interventions. Will be hard to determine which factor contributed to changes observed

• Short time horizons (28-54 months for evaluations)

• Small sample sizes

• Standardizing measurement across pilots and evaluation projects

• High level of enthusiasm among payers and employers . . . Could lead to impatience and premature conclusions

• Potentially underfinanced… more funding partners needed

What Else We’re Supporting

ACP/Urban Institute

• Estimate fixed and incremental costs to become and maintain a medical home

• Outline payment options

NCQA

• Test and propose ways to expand PCMH measures to make more patient-centered

NASHP

• Identify policy options to promote PCMH in Medicaid and SCHIP

• Support 8 states

Massachusetts General Hospital

• Twelve in-depth case studies of high-performing, patient-centered primary care practices

What We’re Not Learning:The Short List

• Interface between primary, specialty and subspecialty care. How can/should payment promote effective coordination between clinicians?

• If all the evaluations show positive results, we will not know which component of the intervention made the difference. Was it the technical assistance? The payment model?

• What are the strengths/weaknesses of various curricula to help practices transform? Need comparative analysis.

• How do we talk to patients about medical home? Should we evaluate best ways to engage patients and families? How incorporate into a busy practice?

• Understanding key components of the PCMH in a practice. For example, what does patient-centered HIT look like? What does team-based care really mean (who, what, etc.)?

• How should training of physicians change? What should the curriculum look like to prepare workforce for medical homes?

Acknowledgements

Visit the Fund at: www.commonwealthfund.org

Elizabeth Hodgman,Program Associate,Patient-Centered Primary Care Initiative