The Medical Home and Physician Payment Reform Discussion Forum October 17, 2007 Debra Ness Co-Chair,...

The Medical Home and Physician Payment Reform

Discussion ForumOctober 17, 2007

Debra NessCo-Chair, Consumer-Purchaser Disclosure Project

President, National Partnership for Women & Families

Peter V. Lee Co-Chair, Consumer-Purchaser Disclosure Project

CEO, Pacific Business Group on Health

© Consumer-Purchaser Disclosure Project, 2007 2

Agenda • Welcome and Introductions• The Patient Centered Medical Home: A New

Model for Primary and Principal Care• Patient-Centered Medical Home: Knowing

When We See One• Medical Home Demonstrations:

– Rhode Island Experience– Private Health Plan– Medicare Pilots


Medical Home Issues• How will this impact patients/consumers?

• Will it make care better and more patient-centered? • Or is this just another gatekeeper system?

• What are the critical essential elements? What are the potential pitfalls?

• Is this a positive step on the path to payment reform?

• What are the short and long term impacts on spending?

• How does this fit in the current context of the SGR debate?


Coordination of Care and the Current “System”: A Mismatch

• Cure vs. care• Single disease vs. comprehensive care• Acute (short-term) vs. chronic (long-term)

care• Health care setting vs. continuous care

approach• Patient (dependent) vs. consumer (partner)

centered


System Failures

• Inconsistent medical management

• Inadequate transfer of information

• Poor communication

• Limited access to services

• Perceived lack of accountability

• Lack of systems to bridge transitions


Context: Utilization in Medicare – Few People, Big Dollars


Private Insurance Making Bad Payments Private Insurance Making Bad Payments Worse – Rewarding Procedures over CareWorse – Rewarding Procedures over Care• 2005 Medicare fee for CPT code 99214: 30 minute office visit2005 Medicare fee for CPT code 99214: 30 minute office visit

– Relative value unit (RVU): Relative value unit (RVU): 2.182.18– Conversion factor:Conversion factor: 37.937.9– Fee 2.18 x 37.9 Fee 2.18 x 37.9 = = $82.62 $82.62

• 2005 Medicare fee for CPT code 45378: colonoscopy (30 minutes)2005 Medicare fee for CPT code 45378: colonoscopy (30 minutes)– RVU: RVU: 5.465.46– Conversion factor: Conversion factor: 37.937.9– Fee 5.46 x 37.9 Fee 5.46 x 37.9 = = $206.93$206.93

• 2005 private insurance fee for CPT code 45378: colonoscopy 2005 private insurance fee for CPT code 45378: colonoscopy – RVU:RVU: 5.465.46– Conversion factor Conversion factor 45.5 (120% of Medicare)45.5 (120% of Medicare)– Fee 5.46 x 45.5Fee 5.46 x 45.5 == $248.43$248.43

• Markets in which gastroenterologists are well organized: colonoscopy feeMarkets in which gastroenterologists are well organized: colonoscopy fee– RVU:RVU: 5.465.46– Conversion factorConversion factor 75.8 (200% of Medicare)75.8 (200% of Medicare)– Fee 5.46 x 75.8Fee 5.46 x 75.8 == $413.87$413.87

Adapted from T. Bodenheimer, M.D., UCSF, May 2006


Medical Home Issues• How will this impact patients/consumers?

• Will it make care better and more patient-centered? • Or is this just another gatekeeper system?

• What are the critical essential elements? What are the potential pitfalls?

• Is this a positive step on the path to payment reform?

• What are the short and long term impacts on spending?

• How does this fit in the current context of the SGR debate?


The Disclosure Project

The Consumer-Purchaser Disclosure Project is a coalition of more than 50 of the nation’s leading consumer, labor, and employer organizations that is working to advance publicly reported, nationally standardized measures of clinical quality, efficiency, equity, and patient centeredness for health plans, hospitals, medical groups, physicians, other providers, and treatments. The Disclosure Project is supported by in-kind support of participating organizations and by financial support from The Robert Wood Johnson Foundation.

For more information: http://healthcaredisclosure.org/

The Medical Home and Physician Payment Reform Discussion Forum October 17, 2007 Debra Ness Co-Chair,...

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