Presentation to WI Academy of Physician Assistants 4/1/09 (.ppt)

210 Green Bay Road, Thiensville, WI 53092Phone: (262) 512-0606

Email: academy@wafp.orgwww.wafp.org/pcmh

Patient Centered Medical Home (PCMH) Patient Centered Medical Home (PCMH) The Wisconsin PerspectiveThe Wisconsin Perspective

Wisconsin Academy of Physician Assistants2009 Spring Conference

April 1, 2009

Alan Schwartzstein, MD, FAAFPWAFP 1st Vice Presidentalan.schwartzstein@deancare.com

Overview of Presentation

Historical Perspective(Video)Background: What is a PCMH?Proof of Value of Primary CareStakeholder Interest/AcceptancePCMH in WisconsinQ and A, Discussion

Take Home Messages1. American health care is currently delivered in a broken

(non) system which results in high costs and low value

2. There are many competing interests in U.S. health care which currently threaten the survival of primary care practice.

3. The patient centered medical home is a new model of care gaining national traction which will free up patients and primary care clinicians to work together on maximizing the health of patients, and is a step towards universal health care access and coverage.

Take Home Messages

4. There is real value to the ongoing relationship a patient has with a primary care clinician that improves health outcomes, lowers health care costs, and reduces disparities in health care access.

5. There is room in the PCMH for Physician Assistants and other advanced practitioners to play the same role or larger than they currently play in primary care practices, and to receive the same or greater compensation.

Historical Perspective

Why Redesign?

When you take any system that’s designed to achieve one result and try to get another without redesigning the system, you don’t get the result you want.

Systems are perfectly designed and operated to produce the results they get.

U.S. (non) Health Care SystemU.S. (non) Health Care System

• Reimbursement is based on acute episodic care

• Reimbursement rewards procedures

• Traditional fee for service payment rewards piecemeal work and volume of services rather than prevention of illness and coordination of care. The more procedures a physician performs, and the higher the value of the procedure, the more the physician is paid.

The Result…The Result…

• Spiraling health care costs• High volume of services• Care that is not coordinated• US ranks #1 in health care costs/patient in the

world and #37 by WHO in quality• US worst record among 19 developed

economies in adding years of life with medical technologies

• Result: Patients and payers are dissatisfied

Primary Care Physician Complaints

• Not enough time to perform tasks• Too much to remember• Too many tasks not reimbursed• Too many non-physician tasks• Work harder/paid less• Life out of balance

Outcome for Primary Care Physicians

• Less than idealAccessServiceQuality of care

• Early specialty referralMore costlyImpairs specialty access

Result: Patient and physician dissatisfaction

And…

• National shortage of primary care physicians– All locations are experiencing a shrinking

primary care physician base– Some internists have recently moved to

hospitalist practice, where they can have better lifestyle and earn more than their office based practice

– Recruiting primary care challenging due to limited pay and work demands

Choice of Specialty

• Future Salary and US Residency Fill Rate Revisited; Ebell– In 1989, a study described a linear correlation between the

median income of physicians in a specialty and the percentage of residency positions for that specialty filled with US graduates (r = 0.85).1 Since that time:

– the disparity in income between primary care and subspecialties persists, and student debt has risen to a median of $140 000 for the class of 2007..

– Ebell repeated study using 2007 data– Percentage of US allopathic medical school graduates choosing

a particular specialty in 2007; and the mean annual salary in 2007 for physicians in different specialties (overall mean and starting salary; AMGA survey), osteopathic and allopathic physicians.

Results• A strong direct correlation between higher overall salary

and higher fill rates with US graduates

– Primary care specialties generally have a lower salary and fill rate; family medicine had the lowest mean salary ($185 740) as well as the lowest fill rate with US seniors (42.1%).

– Orthopedic surgery and radiology had the highest salaries and fill rates, with a ratio between the mean salary of a radiologist and that of a family physician of 2.2.

– Emergency medicine, otolaryngology, and pediatrics had slightly higher fill rates than would be predicted for their salaries.

Copyright restrictions may apply.

Ebell, M. H. JAMA 2008;300:1131-1132.

Percentage of Positions Filled With US Seniors vs Mean Overall Income By Specialty

Comments• Close association between physician salary and residency fill rate

described in 1989 and 2007.

• County, state, and international comparisons have consistently shown that having a greater percentage of physicians in primary care specialties is associated with better population health outcomes, including reduced all-cause, cardiovascular, infant, and cancer-specific mortality.

• However, rising levels of student debt, considerably lower salaries in primary care specialties, and a perception that primary care may have a less rewarding lifestyle have led to a potential workforce crisis given the aging US population.

• Addressing disparities in salary by specialty may need to be part of a solution to this problem.

• Term “medical home” introduced by AAP 1967 for medical records

• Crossing the Quality Chasm, IOM• Expanded 2002 to include core principles from

IOM• AAFP Future of Family Medicine Report 2004• ACP worried about future of general IM• All of primary care seeing lower match rates for

residencies

Joint principles from AAFP, AAP, ACP and AOAoutline the model, attributes, and payment

Structure of a:

Patient Centered Medical Home

http://www.wafp.org/pcmh/attachments/PCMH%20Joint%20Priciples.pdf

Background: What is a PCMH?

Background: What is a PCMH?Background: What is a PCMH?

A Patient Centered Medical Home (PCMH) is amore effective and efficient model of health caredelivery that produces:

• Better health outcomes• Lower costs• Greater equity in health

In a Patient Centered Medical Home:

• Patients have a relationship with a personal physician.• A practice-based care team takes collective

responsibility for the patient’s ongoing care.• The care team is responsible for providing or arranging

all the patient’s health care needs.

In a Patient Centered Medical Home:

• Patients can expect care that is coordinated across care settings and disciplines.

• Quality is measured and improved as part of daily work flow.

• Patients experience enhanced access and communication.

• The practice uses electronic health records, registries & other clinical support systems.

How is a Practice Recognized as a PCMH?How is a Practice Recognized as a PCMH?

NCQA has developed a scored criteria set of standards(PPC-PCMH™) for medical practices to demonstrate thatthey are functioning as PCMHs• Includes a tiered recognition system based upon score

(see www.ncqa.org)

TransforMED has a MHIQ tool to assess a practice’sreadiness

A Patient Centered Medical Home delivers:

• Enhanced payment in a fee-for-service and pay-for-performance environment

• Better organized and more efficient office processes

• Higher physician and staff satisfaction

Payment Structure ReformPayment Structure Reform• Fee for service for face-to-face visits

• Care management fee to recognize added value

• Additional payment for achieving measurable andcontinuous quality improvement

Payment Structure ReformPayment Structure ReformPayment reform must recognize the added valueprovided to patients with Patient Centered MedicalHome

Proof of Value of Primary Care

Value Model

V=Q/C(V=Value, Q=quality, C= cost)

or,Deliver the best possible clinical outcomes at the

least necessary cost.

Starfield Report• Barbara Starfield, Johns Hopkins• Landmark review of dozens of studies comparing health

care in the United States with other countries as well within the U.S.

• Major findings: – Within the United States, adults with a primary care physician

had 33 percent lower costs of care (C) and were 19 percent less likely to die from their conditions than those who received care from a specialist, after adjusting for demographic and health characteristics.

– Primary care physician supply is consistently associated with improved health outcomes (Q) for conditions like cancer, heart disease, stroke, infant mortality, low birth weight, life expectancy, and self-rated care.

Starfield Report (cont.)

• Further Findings:• 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.

• An orientation to primary care reduces socio-demographic and socio-economic disparities. African-Americans who have a primary care physician in particular are less likely to die prematurely.

Commonwealth Fund Study on Racial Disparities in Health Care Outcomes

• After looking and adjusting for all of the variables, found only 2 interventions that effectively reduce health care disparities:– Whether a person has some form of insurance– Whether a person has a ongoing relationship with a

primary care physician (medical home)

Proof of Value to Primary CareA Patient Centered Medical Home delivers:

• Improved patient care and satisfaction

– Ten years of experience at Group Health Cooperative of Puget Sound demonstrated the model can improve the quality and cost-effectiveness of care for patients with chronic diseases.

– Recent studies estimate that if every American had access to a Medical Home, national health care expenditures (C) would drop by 5.6% – translating into a national savings of at least $67 billion per year.

PCMH in PracticePCMH in Practice

North Carolina: 2003 – 2006

Patient Centered Medical Home implementation saves the state of North Carolina more than $200 Millioneach year in health care costs.

PCMH in PracticePCMH in Practice

Community Care of North CarolinaSavings are achieved because physicians:• Proactively assist their patients in staying healthy and

managing existing illnesses or conditions• Coordinate patient care among an organized team of

health care professionals• Utilize systems at the practice level to achieve higher

quality care and better outcomes• Focus on whole person care for their patients

Center for Evaluative Clinical Sciences at Dartmouth study

Patients with severe chronic diseases who live in states in the U.S. that rely more on primary care have:

– lower Medicare spending (inpatient reimbursements and Part B payments)

– lower resource inputs (hospital beds, ICU beds, total physician labor, primary care labor, and medical specialist labor)

– lower utilization rates (physician visits, days in ICUs, days in the hospital, and fewer patients seeing 10 or more physicians)

– better quality of care (fewer ICU deaths and a higher composite quality score).

PCMH: Demonstrated Outcomes

• Happier patients2

• Happier physicians3

• Higher quality1,2,4

• Lower cost2,4

• Enhanced access1,2

1) 2006 Commonwealth Fund survey2) IBM Health Care Model3) Arch Pediatr Adolesc Med 2000; 154:499-5064) Community Care of North Carolina

Conclusion of Studies

• It is clearly proven that there is an tangible value to the ongoing relationship that a patient has with a primary care physician

• It is clear that any health system that wishes to maximize the Value Model must find ways to maximize the number of these relationships for its patients, and provide sufficient resources for patients to access those relationships (i.e., adequate Primary Care Physician workforce)

How Physician Assistants Fitinto the PCMH

(very well)

Physician Assistants in PCMH• Current role in primary care

– see patients under supervision of MD, acute and ongoing care– Old Model: MD did as much as could; delegated rest to others

• PCMH Team role– PCMH Model: all in practice operate to maximum of their training

and ability; frees up MD for newly compensated activities that enhance ongoing relationship for patients with practice

• Physician Assistant maximizes education and skill set

• Opportunity to benefit financially from PMPM and outcome rewards

Stakeholder Interest/Acceptance

Business• Patient Centered Primary Care Collaborative (PCPCC)

– initiated by IBM as a coalition of major employers, consumer groups, organization representing primary care physicians, major national payers, and other stakeholders who have joined to advance the PCMH with the belief that, if implemented it will:

• Improve health of patients (employees) (read: save employers $$$)

• Improve the health care delivery system

• Major Payers agreed in fall 2007 to join PCPCC and work on a multi-payer pilots.– Aetna– BC/BS– CIGNA– Humana– United Health Care– WellPoint

State Legislators• National Conference of State Legislators• Meeting November 2007, passed resolution on

PCMH:• “that the Council of State Governments support

the Joint Principles of the PCMH as a guideline for states to improve the health of its citizens; and

• encourages states to implement and fund pilot programs to demonstrate the quality, safety, value, and effectiveness of the patient-centered medical home”

Medicare MH Demonstration• Motivation

– Unsustainable Medicare cost inflation– Quality of some care is suboptimal– Some care is fragmented and inefficient

• Authorization– Tax Relief and Health Care Act of 2006 (TRHCA), Section 204 – Medicare Improvements for Patients and Providers Act

(MIPPA) of 2008, Section 133

Medicare MH Demonstration• Goals

– Improve care management– Improve quality– Improve patient and provider satisfaction– Reduce costs

Medicare MH DemonstrationPer Member Per Month Payments

Medical Home Tier

Patients with HCC Score <1.6

Patients with HCC Score ≥1.6 Blended

Rate1 $27.12 $80.25 $40.40

2 $35.48 $100.35 $51.70

HCC score indicates disease burden and predicted future costs to Medicare

Nationwide, 25% of beneficiaries have HCC ≥ 1.6, and are expected to have Medicare costs that are at least 60% higher than average

PCMH in Wisconsin

PCMH in WisconsinPCMH in WisconsinAn increasing number of WI practices are in the process of

obtaining NCQA recognition as a Patient Centered Medical Home.

The Wisconsin Academy of Family Physicians (WAFP) is making the advancement of PCMH its #1 priority.

PCMH in WisconsinPCMH in WisconsinThe WAFP Goals, over the next 3-5 years, are:• To help multiple stakeholders understand, embrace and

implement PCMH• To educate payers and legislators about the benefits of

the medical home concept and achieve payment reform• To reform the health care payment system to recognize

We believe the Patient Centered Medical Home is our best hope for meaningful health care reform as evidenced by other successful implementation.

WAFP EffortsWAFP Efforts

What WAFP is doing on the Policy front:• We developed a proposed PCMH Medicaid Payment

Program.• Our lobbyist/leaders are actively talking with Wisconsin

state administrators and legislators about the benefits of PCMH.

• In November, 2008, we testified before the Wisconsin Legislative Council in favor of a PCMH pilot program in the state.

Proposed M/A Payment ProgramProposed M/A Payment Program

Both fee-for-service and care management fees wouldbe increased according to the PCMH recognition levelachieved by the practice:

Level of Recognition

FFS Primary Care Fee Schedule Increase PMPM Care Management Fee

No recognition 0% $0 PMPM

Level 1 2% $5 PMPM

Level 2 4% $10 PMPM

Level 3 6% $15 PMPM

Proposed M/A Payment ProgramProposed M/A Payment Program

For a Wisconsin practice of 5000 patients at Level1 PCMH recognition, that means a potential of$300,000 annually in PMPM payments

Proposed M/A Payment ProgramProposed M/A Payment ProgramUnder the blended payment plan:

if 50% of WI Medical assistance recipients were in a medical home, projected annual savings to state, after increased payments to practices, would be:

>$90 million dollars

WAFP EffortsWAFP Efforts• March 26, 2009 WI Joint Legislative Council adopted the

recommendation on a Patient Centered Medical Home (PCMH) pilot program for MA recipients in Wisconsin.

• Bill introduced will direct WI DHS to establish a PCMH pilot program for the state's Medicaid population.

• Bill requires the increased payments be sufficient to provide a real incentive for providers to participate in the program.

• Bill will be sponsored by the Joint Legislative Council.

Joint Legislative Council• Fred Risser • G. Spencer Coggs • Alberta Darling • Russell Decker • Scott Fitzgerald • Sheila Harsdorf • Pat Kreitlow • Mark Miller • Judy Robson • Dale Schultz • Robert Wirch

• Marlin Schneider• Joan Ballweg• Spencer Black • Terese Berceau • Jeff Fitzgerald • Dean Kaufert • Tom Nelson • Mark Pocan • Michael Sheridan • Tony Staskunas • Robin Vos

For More InformationFor More Information

Visit: www.wafp.org/pcmh Call: Wisconsin Academy of Family Physicians Larry Pheifer, Exec. Dir. (262) 512-0606E-mail: Larry@wafp.org

Thank YouThank You

References• WAFP page on PCMH:

http://www.wafp.org/m_members.asp

• Patient Centered Primary Care Collaborative, www.pcpcc.net

• Community Care of North Carolina web site http://www.communitycarenc.com/

• Future Salary and US Residency Fill RateRevisited; Ebell MH. JAMA.1989;262(12):1630

References (cont.)• Wilson CF. Community care of North Carolina: saving

state money and improving patient care. N C Med J. 2005; 66(3):229-33.

• TransforMED: http://www.transformed.com/

• TransforMED’s Medical Home IQ Assessment (MHIQ) http://www.transformed.com/MHIQ/welcome.cfm

References (cont)• The Relationship Between Primary Care, Income

Inequality, and Mortality in US States, 1980–1995, Leiyu Shi, DrPH, MBA, James Macinko, PhD, Barbara Starfield, MD, MPH, John Wulu, PhD, Jerri Regan, MPA, and Robert Politzer, ScD, J Am Board Fam Pract 2003; 16: 412-22

• Crossing the Quality Chasm: A New Health System for the 21st Century, Institute of Medicine, released March 2001

• The Future of Family Medicine: A Collaborative Project of the Family Medicine Community Ann Fam Med 2004;2:S3-S32. DOI:10.1370/afm.130.

References (cont.)• The Care of Patients with Severe Chronic Illness: A

Report on the Medicare Program by the Dartmouth Atlas Project; Center for the Evaluative Clinical Sciences and Dartmouth Medical School, May 2006

• Closing the Divide: How Medical Homes Promote Equity in Health Care: Results From The Commonwealth Fund 2006 Health Care Quality Survey– June 27, 2007 | Volume 62 Authors: Anne C. Beal,

M.D., M.P.H., Michelle M. Doty, Ph.D., Susan E. Hernandez, Katherine K. Shea, and Karen Davis, Ph.D.

References (cont.)• Patient-Centered Physician Guided Care for the

Chronically Ill: The ACP Prescription for Change, 10/2004

• The Advanced Medical Home: A Patient Centered, Physician Guided Model of Health Care, policy monograph of the ACP, 1/22/2006

Presentation to WI Academy of Physician Assistants 4/1/09 (.ppt)

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