Panel DiscussionThe Medical Home Project
High Peaks Resort,Lake Placid
Saturday, January 31, 2009
Panel
Jeff Stone, MD- Latham Medical Group, a division of Community Care Physicians
Diane Cardwell,MPA, ARNP - TransforMed Brian Morrissey - Capital District Physician’s
Health Plan (CDPHP) Martin Kohn, MD,MS,FACEP,CEP
Introduction - Dr.Jeff Stone TransforMed and the “Patient Centered
Medical Home” - Ms. Diane Cardwell Insurer’s Perspective - Mr. Brian Morrissey Employer’s Perspective - Dr.Martin Kohn Physician’s Perspective - Dr. Jeff Stone
Diane Cardwell, MPA, ARNPPractice FacilitatorJanuary 31, 2009
Patient-Centered Medical HomePatient-Centered Medical Home
Our mission is the transformation of healthcare delivery to achieve optimal patient care, professional satisfaction and success of primary care practices.
How is a PCMH different from what we are already doing?
Patient Centered vs. Provider or Practice Centered
Forms the foundation for a healthcare partnership with patient and care network
Involves proactive care vs. reactive care
Practice culture that advocates for and demands what is needed to provided patient-centered, integrated, coordinated care
Creating a Patient Centered Medical Home
Requires attention to relationships
– Between the practice and the patient
– Among members of the practice
– Between the practice & the community
What we know about Practice Transformation…
Requires a team effort Cannot be achieved merely through new technology Takes time Can take unexpected turns
Critical Success Factors in Transformation
Leadership
Teamwork
Communication
When the leadership “system” is in place the practice’s ability to adopt
change accelerates significantly. Leadership
drives the culture.
Teamwork
Transformation is a
team effort!
CommunicationAs the numbers of people involved in a communication increases, so does the complexity of the communications & the potential for misunderstanding!
Questions?
Brian MorrisseyCDPHP VP, Strategy &
DevelopmentJanuary 31, 2009
Why are Most Health Plans Interested in the Medical
Home?Care delivered by primary care
physicians in a patient-centered medical home is consistently associated with better outcomes, reduced mortality, fewer preventable hospital admissions for patients with chronic diseases, lower utilization, improved patient compliance with recommended care, and lower Medicare spending.
PCMH Evidence Document: PCPCC Call-to-Action Summit 11/7/07
CDPHP’s Interest
SAVING PRIMARY CARE!
Mission & Vision
Vision:– Create an innovative and sustainable model for the
reimbursement of primary care physicians leading to a resurgence in the interest in primary care medicine as a career for medical students. Accomplish this while demonstrating better health outcomes and market-leading satisfaction scores for patients, employers, and physicians.
Mission:– The transformation of primary care practice and payment
mechanisms to enhance the value of health care delivery and primary care physician satisfaction.
“Virtual” All Payer Pilot
Can’t practice two different ways Autonomy Speed Unique commitment of CDPHP
CDPHP Pilot
Practice Reform
Payment Reform
Pilot Hypothesis
Are the aggregate savings associated with better health
outcomes and lower utilization sufficient to fund the enhanced
compensation to a primary care physician?
Payment Reform
Comprehensive payment for comprehensive care
Align financial incentives Create an opportunity to significantly
increase primary care physician income (35 – 50%)
Payment Reform –Compensation Today
90-94% FFS
$1pmpm Care mgmt
Fee
6% Quality Payment
80-90% FFS
10% Quality Payment
$5pmpm Care mgmt
Fee
CDPHP Today Typical MH Pilot
The “Evils” of RBRVS Reimbursement (aka FFS)
Incents more care, not better care Limits innovation in care delivery Unintentionally designed to frustrate providers
and patients by driving down length of visit No incentive for care coordination No incentive for better outcomes Significant driver for the primary care crisis
Payment Reform –CDPHP Pilot
70% Risk Adjusted Comprehensive
Payment *
3%FFS - RBRVS
27% Bonus Payment
* Targeted at improving base reimbursement approximately $35,000 to reflect increased costs of implementing and operating a medical home.
Risks
Both practice and payment reform are really, really hard
ROI may not be demonstrated, or if it exists, may be transient
May end up deploying a model that cannot handle the pressures of the real world
Bigger risk is the Bigger risk is the disappearance ofdisappearance of
primary careprimary care
Questions
IBM in Healthcare and Life Sciences
IBM Healthcare
Martin S. Kohn, MD, MS, FACEP, CEP
November 11, 2008
Our VisionHealthy People for a Productive World
Our Client CommitmentInnovations that improve quality and value,
leading to consumer-centric and personalized healthcare
How do you start to fix the foundational issue around why our healthcare system is so expensive and yet so broken??
0
1000
2000
3000
4000
5000
6000
7000
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
United StatesGermanyCanadaFranceAustraliaUnited Kingdom
Average spending on healthper capita ($US PPP)
Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care Expenditures: What Are the
Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data
Primary care - focus on comprehensive care Many studies show that when our primary care
providers focus on the comprehensive needs of our
employees they end up in the hospital less, the
emergency room less and their overall care costs
less.
Many studies also show that the practice of episodic
care by a partialist (specialist) without someone in
charge of overall care is dangerous, wasteful and
frankly unacceptable.
Starfield B,Shi L. Policy relevant determinants of health: an international perspective. Health Policy 60 (2002) 201–218.. Grumbach K, Bodenheimer T. A primary care home for Americans: putting the house in order. JAMA 2002;288:889-893.. Future of Family Medicine Project Leadership Committee. The future of family medicine: A collaborative project of the family medicine community. Ann Fam Med. 2004;2(Suppl 1):S3–32. 5. The Advanced Medical Home. The American College of Physicians, 2006. 6. Grumbach K, Selby JV, Damberg C, et al: Resolving the gatekeeper conundrum. JAMA. 1999;282:261-266.
IBM envisions a new Healthcare System …
Healthcare system that is built around patientspatients and focused on WellnessWellness – Patient-Centered Medical Home model – providing better
outcomes for patients– Wellness Focus – where physician are paid for effective wellness
management A transformed healthcare system transformed healthcare system where all stakeholders
participate in the transformation ……..– Consumers will assume much greater financial oversight and
responsibility for their healthcare, – Payers will take a more holistic view of value– Societies will understand that healthcare funds are not limitless and
will demand that payment for and quality of healthcare services be aligned with the value
Hospital Systems /
Practice Mgt.Systems
IBM’s Strategy is to Transform Healthcare -- with effective information
exchange
Health Record(EHR)
Payer
Clinical InformationExchange
Employer
Health CardPatientEmployeeMember
Subscriber Services
Capital
Authenticated Access
PHR
Eligibility, Plan DataPlan Pay Advice
Consumer PaymentConsumer AdvicePlan Settlement
Sources of Payment
Membership Stake
Adjudication SettlementMedicare Medicaid
FSAHSA
MasterCardVisa
Amer ExpDiscoverFidelityTricare
Determine
Liability
Updated Accumulators
Request for Payment
Remittance Advice
PatientEmployeeMember
Subscriber
PersonalHealth Record
(PHR)
Manage Care
Access PHR
Use Tools
PHR
Smart Medical Devices
… with ultimate focus on wellness
Comparison of IBM Annual Per Capita Medical Cost
$4,4
01
$4,8
88
$5,5
54 $6,3
58
$7,0
88
$7,7
10
$8,2
35
$4,7
56
$5,2
86
$5,9
82
$6,4
46
$6,8
88
$7,2
31
$7,8
20
$3,000
$6,000
$9,000
2000 2001 2002 2003 2004 2005 2006
AverageIBM
Comparison of Annual Trend in Per Capita Medical Cost (Before EE Contributions)
11.0%
13.6%
11.3%
8.2%
5.6%
6.9%
13.5%
8.6%9.1%
5.0%
13.2%
7.8%
11.1%
8.1%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
2000 2001 2002 2003 2004 2005 2006
Average of Surveys
IBM
IBM has transformed itself and has achieved great results
projected
includes healthy living rebate
Source for benchmarks: Average of survey results from Kaiser Family Foundation, Hewitt Associates, and Towers Perrin
projected
2007 data in currently being finalized
We are the ones we’ve been waiting for
Obama Feb. 5, 2008
The Role of IBM with our Clients and Partners in Patient-Centric
Healthcare Deliver innovative solutions
–Leadership in technology and clinical integration–Improved access to information and optimized workflows–Influential application provider relationships
Drive adoption–Cultivate the global ecosystem–Form relationships with a critical mass of collaborators–Encourage the development of value nets–Lead in open standards
Set an example as a best practices employer–Effectively manage IBM’s Global Health and Wellness
programs–Lead in motivating the use of EHR and PHR–Serve as a Health System advisor
In assuming more responsibility for their care, consumers must
make wiser health and financial decisions as patients and
purchasers
Improve access to information
“Health Coach”• Prediction• Healthy lifestyles• Behavioral Change
Make better health-related
choices
“Wealth Coach”• Financial planning• Financing options• Insurance options
Improve financial planning
for healthcare
“Value Coach”• Health plan benefits• Provider selection• Comparative value
Receive personalized
high-value care
Analysis
Continued shift from employer-based togovernment-based
and individual coverage
Increase in consumer responsibility and
accountability
New healthcare requirements,delivery models, capabilities, and reimbursement models
IBM’S Patient Centered Collaborative Care Process
Care Team Collaboration
Select Care Providers
Select Care Providers
Provide On-going Care
Provide On-going Care
Gather Individual Health InformationGather Individual
Health Information
Measure &Reward
Measure &Reward
Assess HealthAssess Health
Pay for Products& Services
Pay for Products& Services
Enroll Patient inPrograms
Enroll Patient inPrograms
Design Care PlanDesign Care Plan
Improve Process Improve Process
Aggregation of health information Clinical / Biometrics / Claims Comprehensive View Focus on Wellness & Prevention
Enroll in programs Employer Government Self-insured
Risk stratification Determine focus areas Prioritization
Evaluate provideroptions
Consider alter-natives
Fit with needs
Evaluate care options Select treatments,
products, & services Based on clinical
input, quality metrics,personal needs, &health plan options
Execute care plan Acute, chronic, or
wellness plan Collect metrics
to establishefficacy
Payments Health plans Medical home
programs Retail
Monitor performance Clinical procedures &
processes Administrative business
process Program efficacy
Improve outcomes Quality of life Patient Satisfaction ROI
2
3
9
8
7
6
5
4
1
Evidence Generation &
HealthAnalytics
Physicians & Specialists
HealthInformationWarehouse
Patients
Dx, Rx
Pharma, Labs,Diagnostics,
Claims, Other Health
Info
Public Health
Portal Access Layer
Disease Dashboards&
Work Flow
Data Acquisition& Integration
UserPortals & Portlets
HealthInformationOperational
Store
ElectronicMedicalRecords
IBM Pc3 Solution (Conceptual View)
Public DataSources
Patient Portal& Monitoring
QualityMeasures
&PatientSafety
Researchers Case Worker
Clinical Admin
Payer State
PatientIdentityMgmt
Data Integration Layer
ClinicalDecision
Support &Health Analytics
PersonalizedCare
Diagnosis &Treatment
UserInteraction
Process Mgmt
InformationMgmt
En
terprise S
ervice Bu
s
IBM Pc3 will require key questions to be answered
Consumers
Who has the best outcomes?
What preventive tests should I have?
When can I see my doctor?
Do I have immunizations due?
EmployersWhat are my most cost effective care options?How can I measure the wellness of my employees?Who provides the highest quality care?
Physicians and Care Team
What are the outcomes of my patient populations by disease profile?
When are the preventive tests and immunizations due?
How can I better manage my referrals?
How compliant is my practice to key core measures and other metrics?
What are my costs of services?
Health PlansWhat are my member outcomes?Have I reduced the number of unnecessary ER visits?How do I manage and report the progression and impact of chronic diseases such as diabetes or stroke within a system, region or market ?How do I predict high risk populations and begin early interventions?
The Physician’s PerspectiveJeff Stone,MD
Family Physician
Important Philosophy of the PCMH Important Philosophy of the PCMH (AAFP 2008)(AAFP 2008)
Continuing, comprehensive and Continuing, comprehensive and personal care in the context of family personal care in the context of family and community. Taking into account and community. Taking into account the physical, psychological and the physical, psychological and spiritual nature of wellness and disease.spiritual nature of wellness and disease.– Sound familiar? – like maybe the core Sound familiar? – like maybe the core
values of primary carevalues of primary care
48Page 48
How do you start to fix the foundational issue around why our healthcare system is so expensive and yet so broken??
0
1000
2000
3000
4000
5000
6000
7000
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
United StatesGermanyCanadaFranceAustraliaUnited Kingdom
Average spending on healthper capita ($US PPP)
Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data
49Page 49
76 81 88 84 89 8999 97
8897
109 106116 115 113
130 134 128115
65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110
0
50
100
150 1997/98 2002/03
Countries’ age-standardized death rates, list of conditions considered amenable to health care Source: E. Nolte and C. M. McKee, Measuring the Health of Nations: Updating an Earlier Analysis, Health Affairs, January/February 2008, 27(1):58–71
USA worse/1937th by WHO
50Page 50
“We do heart surgery more often than anyone, but we need to, because patients are not given the kind of coordinated primary care that would prevent chronic heart disease from becoming acute.”George Halverson’s (CEO Kaiser) Healthcare Reform Now
The Case for The Medical HomeThe Case for The Medical Home
Important Philosophy of the PCMH Important Philosophy of the PCMH (AAFP 2008)(AAFP 2008)
Continuing, comprehensive and Continuing, comprehensive and personal care in the context of family personal care in the context of family and community. Taking into account and community. Taking into account the physical, psychological and the physical, psychological and spiritual nature of wellness and disease.spiritual nature of wellness and disease.– Sound familiar? – like maybe the core Sound familiar? – like maybe the core
values of primary carevalues of primary care
Questions?
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