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Jim Stout, MD, MPH A. Chris Olson, MD, MHPAProfessor of Pediatrics President
University of Washington Washington Chapter of the AAPClinical Professor
University of Washington
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Value of Primary Care Medical Home Model Care Coordination Family-Centered Care Quality Improvement
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Undervaluing E&M Codes predominately provided by PCP’S
RVU’s determinations that overvalue some services/procedures to the detriment of other services in Medicare’s budget neutral system
Not paying for those services required to allow the PCP to provide patient-focused, longitudinal, coordinated care.
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Cuts to reimbursement that disproportionately adversely impact primary care physicians
Providing incentives for volume of services with no regard to the quality or efficiency of the clinical service provided
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“The collapse of primary care will result in our health care system becoming increasingly fragmented, over-specialized, and inefficient – and lead to poorer quality, higher costs, reduced access, and increased patient dissatisfaction.” Reform of the Dysfunctional Healthcare Payment and Delivery System American College of Physicians, A position paper. 2006
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States with higher ratios of primary care to specialty care have better health outcomes.
Areas with more specialists have higher per captia Medicare spending
Increase in primary care physicians is associated with a significant increase in quality of health services, as well as a reduction in costs.
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Cross national comparisons indicate that nations with stronger primary care infrastructures have lower rates of premature births, deaths form treatable conditions, and post neonatal mortality.
Studies have repeatedly demonstrated that the vast majority of Americans prefer a sustained relationship with a primary care provider.
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Primary care oriented countries achieve notably better outcomes for health in early childhood: low birth weight rations, postneonatal mortality, infant mortality, and child mortality, including deaths from injury.
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The American Academy of Family Physicians believes that everyone should have a personal medical home that serves as the focal point through which all individuals-regardless of age, sex, race, or socioeconomic status-receive acute, chronic, and preventive medical services. Through an on-going relationship with a family physician in their medical home, patients can be assured of care that is not only accessible but also accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians. (May Board 2006)
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“Attributes of the advanced medical home include promotion of continuous healing relationships through delivery of care in a variety of care settings according to the needs of the patient and skills of the medical provider. Physicians are once again partners in coordinating and facilitating care to help patients navigate the complex and often confusing health care system by providing guidance, insight and advice in language that is informative and specific to patients’ needs.”
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Increased patient and family satisfaction Establishment of a forum for problem solving Improved coordination of care Enhanced efficiency for children, youth, and
families Efficient use of limited resources Increased professional satisfaction Increased wellness resulting from comprehensive
care Provide a basis for quality improvement in the
care of children and families
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What is a Medical Home?NOT just a building or place but a way of providing
health care services that are:
• Accessible • Family-centered• Coordinated• Comprehensive• Continuous• Compassionate • Culturally Sensitive
Personal physician vs. team of providers Care Coordination Quality and Safety
◦ “Physician in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement”
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Payment Discussion◦ Recognizes the added value provided to patients
who have a patient-center medical home. ◦ Recognize case mix differences in the patient
population◦ Separate fee-for-service payments for face to face
and other management services ie. Care coordination
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Primary care is on the verge of collapse Very few young physician are going into primary care
(EROAD) There will not be enough primary care physicians to take
care of an aging population with growing incidences of chronic diseases
Without primary care, the health care system will become increasingly fragmented, over specialized, and inefficient. Leading to poorer quality care at higher costs
When compared with other developed countries, the United States ranked lowest in its primary care functions and lowest in health care outcomes, yet highest in health care spending.
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The Secretary shall establish a medical home demonstration project to redesign the health care delivery system to provide targeted, accessible, continuous and coordinated, family-centered care to high-need populations and –◦ Care management fees are paid to personal physicians◦ Incentive payments are paid to physicians participating in
practices that provide a medical home “High-need population” means individuals with
multiple chronic illnesses
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Medical Home Demonstration project tied to SCHIP reauthorization
Demonstration Project Aims◦ Increase cost efficiency◦ Increase access to appropriate services◦ Increase patient satisfaction◦ Decrease inappropriate ED utilization◦ Decrease service duplication
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Provide appropriate preventive care Provide appropriate referrals to
multidisciplinary services Increase school attendance Increase agreed upon measures of quality
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Implementation phase Practice Change Principles Family involvement in practice change Increases interest in practice
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Changing a pediatric practice is like trying to change the tire on a bicycle while you are riding it
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Implementation phase Practice Change Principles Family involvement in practice change Increases interest in practice
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Knowledge Persuasion Decision Implementation Confirmation
Late Majority
Early Majority
Early Adopters Traditionalists
Innovators
2% 13% 35% 35% 15%
Year
Nu
mb
er o
f F
arm
ers
in C
om
mu
nit
ies
100
150
200
250
300
0
50
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
Source: Based on Ryan and Gross (1943).
Cumulative Number of Adopters
Expert Planning
Group Meeting
Refine Collaborative
Design
Change Concepts
Participants
LS 1 LS2(Oct)
LS 3(March)
Phone
Assessments
SupportsVisits
Documents
Prework P
S
A D
P
S
A D
Action Period 2
Action Period 3
Action Period 1
Closeout
Institute for Healthcare Improvement
P
S
A D
We are here
Union Avenue Pediatrics/ Neurobehavioral Assoc.
Swedish Children's Clinic Ida Karlin Pediatrics Virginia Mason Sand Point Pediatrics SW Washington Medical Center
(Vancouver) Healthy Steps
Measure 3 - Diagnostic Information Obtained
0%
20%
40%
60%
80%
100%
Months
%
Goal
Measure 8 - Management Plan
0%
20%
40%
60%
80%
100%
Months
Perc
ent
%
Goal
Measure 6 - ID of Race/Ethnicity and
Language Preference
0%
20%
40%
60%
80%
100%
Months
%
Goal
International Community Health Services Swedish Children's Clinic Ida Karlin Pediatrics Columbia Basin Health Assoc. Polyclinic Pediatrics Group Health - Tacoma South Pediatrics
Measure 1 - Current Severity
0%
20%
40%
60%
80%
100%
Months%
Goal
Measure 3 - Evaluation of Environmental Triggers
0%
20%
40%
60%
80%
100%
Months%
Goal
Measure 7 - Number of Symptom Free Days in
Previous 2 Weeks
0
2
4
6
8
10
Months
Measure 14 - Influenza Immu Annually
0%
20%
40%
60%
80%
100%
Months%
Goal
Measure 9 - Well-Child Visit
0%
20%
40%
60%
80%
100%
Months%
Goal
Valley Family Medicine Skagit Pediatrics CMCC/Mary Bridge Children's Health Center Odessa Brown Children's Clinic Eastgate Public Health Center Northwest Pediatric Center, Inc. Virginia Mason Sand Point Pediatrics Polyclinic Pediatrics
Measure 3 - BMI w /Classified Weight
0%
20%
40%
60%
80%
100%
Months
%
Goal
Measure 7 - Current Self-Management Goal
0%
20%
40%
60%
80%
100%
Months
%
Goal
Measure 6 - ID of Race/Ethnicity and Language Preference
0%
20%
40%
60%
80%
100%
Months
%
Goal
Expert Planning
Group Meeting
Refine Collaborative
Design
Change Concepts
Participants
LS 1 LS2(Oct)
LS 3(March)
Phone
Assessments
SupportsVisits
Documents
Prework P
S
A D
P
S
A D
Action Period 2
Action Period 3
Action Period 1
Closeout
Institute for Healthcare Improvement
P
S
A D
We are here
“Impedimento non mi piega”Leonardo daVinci
Raises eligibility to 250% of poverty (Family of four $50,000) and in 2009 to 300% poverty
Funding for outreach Increase reimbursement to providers Quality measures
◦ “Shall identify explicit performance measures that indicate that a child has an established and effective medical home”
◦ Such as Vaccine rates Well child care utilization
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Care management of children with chronic illnesses
Emergency room utilization Preventive oral health service utilization Report by December 2007 Reimbursement in 2009 related to
measurements of quality
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Value of medical home concept in developing case for primary care◦ Ability to frame the issue of increasing access to a
medical home is good for the state and the families ◦ Financial realities of the small businesses that provide
the medical home for families◦ Great to have insurance but if no provider can afford to
see patients, insurance alone won’t solve the problem. Governor’s agenda Legislative agenda Relationships
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What has been your experience in promoting medical home?
What tools do you need to implement medical home in your practice, your community of physicians?
What are your barriers to implementation and quality measures?
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