Edwina RogersExecutive Director

Patient Centered Primary Care Collaborative601 Thirteenth St., NW, Suite 400 North

Washington, D.C. 20005Direct: 202.724.3331Mobile: 202.674.7800

erogers@pcpcc.net

Patient Centered Primary Care Collaborative

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Overview of Activity

•27 Multi-stakeholder Pilots in 18 States•8 State Medicare Pilots Planned for 2009•44 States and the District of Columbia Have Passed over 330 Laws and/or Have PCMH Activity

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Pilots in planning phase for 2009 implementation

Multi-Stakeholder demonstrationPilot activity in early stages of development

Pilots in progress

Blue Cross Blue Shield Plan Pilots

(as of January 2009)

Some New 2009 Single-Payer Health Some New 2009 Single-Payer Health Plan Demonstration PilotsPlan Demonstration Pilots

= New Demonstration Pilots Taking Place or in the Process of Being Enacted

Key PCMH Pilot Programs Either in Place or in

Development

•Cigna PCMH Pilot in New Hampshire•Aetna has PCMH Pilots in

•Colorado•Maine•Mid-Hudson Valley•Pennsylvania•Central New Jersey

•Priority Health PCMH Pilot Program in Michigan•Wellpoint, Inc. PCMH Pilot in New York City•UnitedHealth Medical Home Pilot in Arizona (Tucson & Phoenix)•Blue Cross Blue Shield PCMH Pilot in Nebraska in early stages of development

State Initiatives to Advance Medical State Initiatives to Advance Medical HomesHomes

in Medicaid/SCHIPin Medicaid/SCHIP

= Identified to have a medical home initiative

Source: National Academy for State Health Policy State Scan, November

2008

Patient-Centered Medical Home2009 Overview of Pilot Activity and Planning Discussions

RI

Multi-Payer pilot discussions/activity

Identified pilot activity

No identified pilot activity – 6 States

Overview of the PCPCC

We are now in our 4th year. Over 650 signing members Advancing the Patient Centered Medical Home

(PCMH) concept in the public and private sectors Hosting Meetings, Summits and Congressional

Briefings Weekly Call Thursday at 11:00 AM EST

Call-in Number: 712.432.3900 Passcode: 471334#

Weekly “Center” calls established to operationalize work of PCPCC

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History of the Medical Home Concept

The first known documentation of the term “medical home” Standards of Child Health Care, AAP in 1967 by the AAP Council on Pediatric Practice -- “medical home -- one central source of a child’s pediatric records” History of the Medical Home Concept Calvin Sia, Thomas F. Tonniges, Elizabeth Osterhus and Sharon Taba Pediatrics 2004;113;1473-1478

Patient Centered – IOM I would strongly urge the adoption of the Danish model of the Patient Centered

Medical Home -- Karen Davis Commonwealth Fund 2009 Medical Home Wikipedia page: http://en.wikipedia.org/wiki/Medical_home

Henrik Jensen Niels Rossing M.D.

Collaborative PrinciplesThe Patient Centered Primary Care Collaborative is a coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, clinicians and many others who have joined together to develop and advance the patient centered medical home. The Collaborative believes that, if implemented, the patient centered medical home will improve the health of patients and the viability of the health care delivery system. In order to accomplish our goal, employers, consumers, patients, clinicians and payers have agreed that it is essential to support a better model of compensating clinicians.

Compensation under the Patient-Centered Medical Home model would incorporate enhanced access and communication, improve coordination of care, rewards for higher value, expand administrative and quality innovations and promote active patient and family involvement. The Patient-Centered Medical Home model will also engage patients and their families in positive ongoing relationships with their clinicians. Further, the Patient-Centered Medical Home will improve the quality of care delivered and help control the unsustainable rising costs of healthcare for both individuals and plan-sponsors.

If you agree, please visit us at www.pcpcc.net and join today!

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The Patient-Centered Primary Care Collaborative

ACP

Providers 333,000

primary carePurchasers –Most of the Fortune 500

Payers Patients

AAP AAFP AOA

ABIM ACC ACOI AHI

IBM Ohio

General Electric

FedEx

Microsoft

Dow

Merck & Co.

Business Coalitions

BCBSA United

Aetna

CIGNA

Humana

WellPoint

Kaiser Permanente

AARP AFL-CIO National Consumers League SEIU

Foundation for Informed Decision Making

Examples of Broad Stakeholder Support & Participation

The Patient-Centered Medical Home 80 Million lives

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Geisinger

Iowa

Patient Centered Primary Care Collaborative Four ‘Centers’ - Over 770 volunteer members

Center for Multi-Stakeholder Demonstration: Identify community-based pilot sites in order to test and evaluate the concept; offer hands-on technical assistance, share best practices, and identify funding sources to advance adoption.

Center to Promote Public Payer Implementation: Assist state Medicaid agencies and other public payers as they implement and refine programs to embed the Patient Centered Medical Home model by offering technical assistance; sharing best practices and giving guidance on the development of successful funding models.

Center for Health Benefit Redesign and Implementation: Create standards and buying criteria to serve as a guide and tool for large and small employers/purchasers in order to build the market demand for adoption of the Medical Home model.

Center for eHealth Information Adoption and Exchange: Evaluate use and application of information technology to support and enable the development and broad adoption of information technology in private practice and among community practitioners.

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JOINT PRINCIPLES OF THE PCMH (FEBRUARY

2007)The following principles were written and agreed upon by the four Primary Care Physician Organizations – the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association.

Principles:Ongoing relationship with personal physicianPhysician directed medical practiceWhole person orientationCoordinated care across the health systemQuality and safety Enhanced access to carePayment recognizes the value added

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ENDORSEMENTS

The PCMH Joint Principles have received endorsements from 18 specialty health care organizations:•The American Academy of Chest Physicians •The American Academy of Hospice and Palliative Medicine •The American Academy of Neurology •The American College of Cardiology •The American College of Osteopathic Family Physicians •The American College of Osteopathic Internists •The American Geriatrics Society •The American Medical Directors Association •The American Society of Addiction Medicine •The American Society of Clinical Oncology •The Society for Adolescent Medicine •The Society of Critical Care Medicine •The Society of General Internal Medicine •American Medical Association•Association of Professors of Medicine•Association of Program Directors in Internal Medicine•Clerkship Directors in Internal Medicine•Infectious Diseases Society of Medicine

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Publically available

information

•Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs.

8Source: Health2 Resources 9.30.08

Defining the Medical Home

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PCPCC Payment ModelMay 2007

Key physician and practice accountabilities/ value added

services and tools

Proactively work to keep patients healthy and manage existing illness or conditions

Coordinate patient care among an organized team of health care professionals

Utilize systems at the practice level to achieve higher quality of care and better outcomes

Focus on whole person care for their patients (including behavioral health)

Perfo

rman

ce S

tan

dard

s

Incentiv

es

Incentives

Incentives

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EVIDENCE OF COST SAVINGS & QUALITY

IMPROVEMENT•Barbara Starfield of Johns Hopkins University•Within the United States, adults with a primary care physician rather than a specialist had 33 percent lower costs of care and were 19 percent less likely to die.•In both England and the United States, each additional primary care physician per 10,000 persons is associated with a decrease in mortality rate of 3 to 10 percent.•In the United States, an increase of just one primary care physician is associated with 1.44 fewer deaths per 10,000 persons.

Commonwealth Fund has reported:• A medical home can reduce or even eliminate racial and ethnic disparities in access and quality for insured persons.

Denmark has organized its entire health care system around patient-centered medical homes, achieving the highest patient satisfaction ratings in the world. Denmark has among the lowest per capita health expenditures and highest primary care rankings.

Center for Evaluative Clinical Sciences at Dartmouth, states in the US relying more on primary care have:•lower Medicare spending,•lower resource inputs, •lower utilization, and •better quality of care.

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EVIDENCE OF COST SAVINGS & QUALITY

IMPROVEMENT

NC Savings (FY04)

Category of Service Estimated Savings from Benchmark

Inpatient $142,085,680

Outpatient $51,865,028

Emergency Room $25,944,553

Primary Care, Specialist $45,498,709

Pharmacy $(15,526,996)

Other $(5,065,238)

Totals $244,801,735

Simple Cost Avoidance

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1919

• 84% of the time, the 14 most common physical complaints have no identifiable organic etiology1

• 80% with a behavioral health disorder will visit primary care at least 1 time in a calendar year2 ; 67% with a behavioral health disorder do not get behavioral health treatment3

• 50% of all behavioral health disorders are treated in primary care3

• 48% of the appointments for all psychotropic agents are with a non-psychiatric primary care provider4

• 30-50% of referrals from primary care to an outpatient behavioral health clinic don’t make first appt5.6

• Two-thirds of primary care physicians (N=6,660) reported not being able to access outpatient behavioral health for their patients. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by PCPs as important barriers to mental health care access7

6. Hoge et al., JAMA. 2006;95:1023-1032.; 7. Cunningham, Health Affairs. 2009; 3:w490-w501.

Patient-Centered Medical Home Team ApproachBehavioral Health Needs in Primary Care Practice

1. Kroenke & Mangelsdorf, Am J Med. 1989;86:262-266; 2. Narrow et al., Arch Gen Psychiatry. 1993;50:5-107; 3. Kessler et al., NEJM. 2006;353:2515-23; 4. Pincus et al., JAMA. 1998;279:526-531’ 5. Fisher & Ransom, Arch Intern Med. 1997;6:324-333;

Patient-Centered Medical Home Cost of Unmet Behavioral Needs

• Healthcare use/costs twice as high in diabetes and heart disease patients with depression1

1. Original source data is the U.S. Dept of HHS the 2002 and 2003 MEPS. AHRQ as cited in Petterson et al. “Why there must be room for mental health in the medical home (Graham Center One-Pager) ; 2. Hertz RP, Baker CL. The impact of mental disorders on work. Pfizer Outcomes Research. Publication No P0002981. Pfizer; 2002; 3. Unützer et al., American Journal of Managed Care 2008;14:95-100.

• Untreated mental disorders in chronic illness is projected to cost commercial and Medicare purchasers between $130 and $350 billion annually2

• Approximately 217 million days of work are lost annually to related mental illness and substance use disorders (costing employers $17 billion/year)2

• Depression treatment in primary care - $3,300 lower total health care cost over 48 months3

Annual Cost – those without MH condition

Annual Cost – those with MH condition

Heart Condition $4,697 $6,919

High Blood Pressure

$3,481 $5,492

Asthma $2,908 $4,028

Diabetes $4,172 $5,559

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Physical Illness

Whole Person OrientationSystem Integration and Transformation Needed

Note: Stand alone mental health services could be paid for from the general medical budget, much as stand alone rehabilitation, eye, and cardiac services

Kathol, 2009

Mental Health & Substance Use Disorders

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• Matching Physical and Mental Health Services to Patient Needs through:

• Co-located and fully integrated physical & mental health personnel

OR

• Tightly coordinated mental & physical health services

• Common mental & physical health documentation system

• Unified outcomes analysis

Behavioral Health is an Inseparable Part of General Medical Health

At least 14 Independent Evaluations in 11 States . . . And Growing

RI

CMS will select 8 states for the Medicare Medical Home Demonstration

Several PCMH Evaluations Underway…

Approximately 14 independent evaluations represented in the PCMH Evaluators’ Collaborative (other evaluators are welcome to participate)

The evaluations are examining a breadth of demonstrations: From one payer to multi-payer pilots

Involve anywhere from 5-70 primary care practices with 28-250 clinicians

Include 27,000 -- 1,000,000 beneficiaries

Many include safety net centers, pediatric sites and Medicaid as a payer

Variety of payment models (hybrid, PMPM, annual comprehensive PC fee)

All have the evaluations have comparison groups

Key Questions Under Investigation: What does it take to become a medical home?

Do PCMHs improve:

Clinical Quality?

Patients’ Experiences?

Physician/Staff Experience?

Efficiency?

Is this sustainable/ are practices financially stable?

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Standard 1: Access and CommunicationA. Has written standards for patient access and patient communication**B. Uses data to show it meets its standards for patient access and communication**

Pts

459

Standard 2: Patient Tracking and Registry FunctionsA. Uses data system for basic patient information(mostly non-clinical data)B. Has clinical data system with clinical data insearchable data fieldsC. Uses the clinical data systemD. Uses paper or electronic-based charting tools to organize clinical information**E. Uses data to identify important diagnoses and conditions in practice**F. Generates lists of patients and reminds patients and clinicians of services needed (population management)

Pts

2

33

64

321

Standard 3: Care ManagementA. Adopts and implements evidence-based guidelines for three conditions **B. Generates reminders about preventive services forcliniciansC. Uses non-physician staff to manage patient careD. Conducts care management, including care plans,assessing progress, addressing barriersE. Coordinates care//follow-up for patients whoreceive care in inpatient and outpatient facilities

Pts

3

43

55

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Standard 4: Patient Self-Management SupportA. Assesses language preference and othercommunication barriersB. Actively supports patient self-management**

Pts

246

Standard 5: Electronic PrescribingA. Uses electronic system to write prescriptionsB. Has electronic prescription writer with safety checksC. Has electronic prescription writer with cost checks

Pts3328

Standard 6: Test TrackingA. Tracks tests and identifies abnormal resultssystematically**B. Uses electronic systems to order and retrieve tests and flag duplicate tests

Standard 7: Referral TrackingA. Tracks referrals using paper-based or electronicsystem**

Pts

7613Pts44

Standard 8: Performance Reporting andImprovementA. Measures clinical and/or service performanceby physician or across the practice**B. Survey of patients’ care experienceC. Reports performance across the practice or byphysician **D. Sets goals and takes action to improveperformanceE. Produces reports using standardized measuresF. Transmits reports with standardized measureselectronically to external entities

Pts

3

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321

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Standard 9: Advanced Electronic CommunicationsA. Availability of Interactive WebsiteB. Electronic Patient IdentificationC. Electronic Care Management Support

Pts1214

**Must Pass Elements

NCQA PPC-PCMH Content and Scoring

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NCQA PPC-PCMH Scoring

Level of Qualifying

Points Must Pass Elementsat 50% Performance Level

Level 3 75-100 10 of 10

Level 2 50-74 10 of 10

Level 1 25-49 5 of 10

Not recognized 0-24 <5

Levels: If there is a difference in Level achieved between the number of points and “Must Pass”, the practice will be awarded the lesser level; for example, if a practice has 65 points butpasses only 7 “Must Pass” Elements, the practice will achieve at Level 1.

Practices with a numeric score of 0 to 24 points or less than 5 “Must Pass” Elements are not Recognized.

Meaningful Use: Meaningful Connections

Defines health IT capabilities essential to PCMH.

Crosswalks capabilities with functional priorities supporting PCMH.

Explores how patients/consumers are currently using health IT to connect.

Representative sample of 19 case example responses from primary care providers.

Appendices include Guidelines for PCMH

Demonstration Projects Consumer Principles Consumer Toolkit

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Patient Centered Primary Care Collaborative

“Purchaser Guide” Released July, 2008

Developed by the PCPCC Center for Benefit Redesign and Implementation in partnership with NBCH and the Center’s multi-stakeholder advisory panel.

Guide offers employers and buyers actionable steps as they work with health plans in local markets - over 6000 copies downloaded and/or distributed.

Includes contract language, RFP language and overview of national pilots.

Includes steps employers can take to involve themselves now in local market efforts.

The PCPCC is holding a series of Webinars, sponsored by Pfizer, on the Purchaser Guide.

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Patient Centered Primary Care Collaborative

“Proof in Practice– A Compilation of Patient Centered Medical Home Pilot and Demonstration Projects” Released

October 2009

Developed by the PCPCC Center for Multi-stakeholder Demonstration through a grant from AAFP offering a state-by-state sample of key pilot initiatives.

Offers key contacts, project status, participating practices and market scan of covered lives; physicians.

Inventory of : recognition program used, practice support (technology), project evaluation, and key resources.

Begins to establish framework for program evaluation/ market tracking.

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Information Flow- Consumer Materials

What consumers can expect- PCMH consumer principles (brochure) Guidance to create

your own practice brochure in support of PCMH model (paper)

Four minute video for waiting room viewing; deep-dive on PCMH (Flash)

Promotes Primary Care (brochure)

Deep-dive focus on PCMH (brochure)

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Patient Centered Primary Care Collaborative

“A Collaborative Partnership – Resources to Help Consumers Thrive in the Medical Home” Released October 2009

Included in the Guide:1. PCPCC activities and initiatives supporting consumer engagement;2. Research and examples surrounding consumer engagement in PCMH demonstrations;3. Tools for consumers and other stakeholders to assist with PCMH education, engagement and partnerships; and4. A catalogue of resources that provides descriptions of and the means to obtain potential resources for consumers,

providers and purchasers seeking to better engage consumers.

Inclusion of the Medical Home Concept in Health Reform

Efforts

Employer Trade Associations

Think Tanks

ExecutiveBranch

Plans developed by Congressional Representatives

The Patient-Centered Medical Home

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Statement on the PCMH: President Obama

“I support the concept of a patient-centered medical home, and as part of my health care plan, I will encourage and provide appropriate payment for providers who implement the medical home model, including physician-directed, interdisciplinary teams, care management and care coordination programs, quality assurance mechanisms, and health IT systems which collectively will help to improve care.”

President Barack Obama

PCMH - HOUSE OF REPRESENTATIVES ACTIVITY

The House Tri-Committee Health Reform Draft

On June 19, 2009 the Chairmen of the three committees with jurisdiction over health policy in the U.S. House of Representatives unveiled their discussion draft for health care reform. Included in this draft is language on the Patient Centered Medical Home (PCMH). 

The draft bill includes funding of $350 million for PCMH pilot programs, which include Independent PCMHs and Community-based Medical Homes.

•'The Secretary shall establish a medical home pilot program (in this section referred to as the ‘pilot program’) for the purpose of evaluating the feasibility and advisability of reimbursing qualified patient-centered medical homes for furnishing medical home services (as defined under subsection (b)(2)) to high need beneficiaries (as defined in subsection (b)(1)).' 

•On July 14, 2009 legislative language was released.

•Sec.1822. Medical Home Pilot Program. Establishes a 5-year pilot program to test the medical home concept with high-need Medicaid beneficiaries. The federal government would match costs of community care workers at 90% for the first two years and 75% for the next 3 years, up to a total of $1.235 billion.

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PCMH - SENATE ACTIVITY

•The Senate HELP Committee released the ‘Affordable Health Choices Act’ on June 9, 2009 outlining the committee’s option for health care reform.

Section 212 of the draft legislation - ‘Grants to Establish Community Health Teams to Support a Medical Home Model’ stated that:• The Secretary of HHS would establish a grant program to creating the “community health team which is community-based, multi disciplinary, interprofessional teams (on the model of medical home) to increase access to comprehensive coordinated care.Enhancing Health Care Workforce Education and Training - There is language in the bill also aimed to enhance health care workforce education and training in Family Medicine, General Internal Medicine, General Pediatrics, and Physician Assistantship by providing grants to develop and operate training programs, financial assistance of trainees and faculty, and faculty development in primary care and physician assistant programs. Priority is given to programs that educate students in team-based approaches to care, including the patient-centered medical home. Authorization is set at $125 million.Health literacy and shared decision making.

•The Senate Finance Committee released their own health care reform proposal. The Senate Finance Committee bill aims to accomplish the following:

•Create a new Medicaid state plan option under which Medicaid enrollees with at least two chronic conditions, or those with one chronic condition who are at risk of developing another chronic condition, could designate a provider as their health home. Qualifying providers would have to meet certain standards established by the Secretary. •Require the Secretary to create, within the Centers for Medicaid and Medicare Services (CMS), an Innovation Center, a new office authorized to test, evaluate, and expand different payment structures and methodologies that aim to foster patient-centered care, improve quality, and slow the rate of Medicare cost growth.•The Center would be required to consider for testing, among other areas, models that promote broad payment and practice reform in primary care, including patient-centered medical home models for high-need beneficiaries, medical homes that address women’s unique health care needs, and those that transition primary care practices away from fee-for-service based reimbursement and toward comprehensive payment. •Provide a new ten percent bonus on for certain primary care practitioners beginning in January 1, 2011. •Provide Medicare direct and indirect Graduate Medical Education funding for Teaching Health Centers 34

UPCOMING COLLABORATIVE EVENTS

Thursday October 22, 2009 - Washington D.C., Annual Summit - Washington Convention Center

Tuesday, March 30, 2010 - Washington D.C., Stakeholder Meeting - Ronald Reagan Building and International Trade Center

Thursday, July 22, 2010 - Washington D.C., Stakeholder Meeting - Ronald Reagan Building and International Trade Center

Thursday, October 21, 2010 - Washington D.C., Annual Summit - Ronald Reagan Building and International Trade Center

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www.pcpcc.net

About the PCPCC History Members Brochure Executive Committee Advisory Board Officers Executive Bios

The Patient Centered Medical Home

Joint Principles Endorsements by Specialists Employer Perspectives Evidence of Quality Health Reform Proposal Reimbursement Model

Collaborative Centers Center to Promote Public Payer

Implementation Center for Multi-Stakeholder

Demonstration Center for Benefits Redesign and

Implementation Center for eHealth Information

Exchange and Adoption

Other PCMH Resources Pilot Project Guide Purchasers Guide Evidence Documents Consumer Materials Events

National Weekly Call Thursday, 11:00AM EST

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CONTACT INFORMATION

Visit our website – http://www.pcpcc.netTo request any additional information on the PCMH or the Patient Centered Primary Care Collaborative please contact:

Edwina RogersPatient Centered Primary Care CollaborativeExecutive Director202.724.3331 202.674.7800 (cell)erogers@pcpcc.netThe Homer Building601 Thirteenth St., NW, Suite 400 NorthWashington, DC 20005

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