THE PATIENT-CENTERED MEDICAL HOME (PC-MH)

THE PATIENT-CENTERED MEDICAL HOME (PC-MH)

THE OKLAHOMA PERSPECTIVE

STEVEN A. CRAWFORD, M.D.2007 CHAIR, AAFP COMMISSION ON

GOVERNMENTAL ADVOCACY

PROFESSOR & CHAIROU COLLEGE OF MEDICINE

DEPARTMENT OF FAMILY & PREVENTIVE MEDICINE

Hamster Health Care

Joseph E. Scherger, MD, MPH; ICSI/IHI Colloquium, May 18, 2007

Hamster Health Care

“Across the globe doctors are miserable because they feel like hamsters on a treadmill. They must run faster just to stand still ….

The result of the wheel going faster is not only a reduction in the quality of care but also a reduction in professional satisfaction and burnout among doctors.”

Ian Morrison & Richard Smith. BMJ. 2000;321:1541-1542

TOPICS

• WHAT IS A PC-MH?• WHY IN OKLAHOMA?• WHAT HAS BEEN DONE SO

FAR?• WHAT IS IN THE FUTURE?• WHAT SHOULD BE DONE?

What is a PC-MH?

A PC-MH is a proposal to organize care based on the Institute of Medicine’s definition of patient-centered care:

•

“providing care that is respectful of and responsive to individual patient preferences, needs, values and

ensuring that patient values guide all clinical decisions”

Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st century, March 2001; Presentation to the Patient-Centered Primary Care Collaborative: Call-to-Action Summit; Bob Doherty, SVP, Governmental Affairs and Public Policy American College of Physicians

What is a PC-MH?

CORE FEATURES OF A MEDICAL HOME

• Personal Physician• Physician Directed Medical Practice• Whole Person Orientation• Care is Coordinated and/or

Integrated• Quality and Safety• Enhanced Access• Payment Reform

Joint Principles of the patient-centered medical home. www.medical-homeinfo.org/Joint%20Statement.pdf 10-24-07

http://www.medical-homeinfo.org/Joint%20Statement.pdf

WHY IS IT IMPORTANT?

• In the U.S., PCP supply is consistently associated with improved health outcomes for conditions like cancer, heart disease, stroke, infant mortality, low birth weight, life expectancy, and self-rated care.

• In England, each additional PCP per 10,000 persons is associated with a approximate 6% decrease in mortality.

• In the U.K., an increase in PCP’s resulted in a significant decrease in both acute and chronic hospital admissions.

Starfield B. Shi L, and Macinko J. Contributions of Primary Care to Health Systems and Health, Millbank Quarterly, Vol. 83, No. 3, 2005 (457-502)


U.S. adults who reported having a PCP rather than a specialist as their regular source of care had lower 5 year mortality rates after controlling for initial differences in health status, demographics, health insurance status, health perceptions, reported diagnosis, and smoking status.

Starfield B. Shi L, and Macinko J. Contributions of Primary Care to Health Systems and Health, Millbank Quarterly, Vol. 83, No. 3, 2005 (457-502)


In the U.S., when adults have a medical home, access to needed care, receipt of routine preventive screenings, and management of chronic conditions improve substantially.

A. C. Beal, M. M. Doty, S. E. Hernandez, K. K. Shea, and K. Davis, Closing the Divide: How Medical Homes Promote Equity in Health Care: Results From The Commonwealth Fund 2006 Health Care Quality Survey, The Commonwealth Fund, June 2007

WHO CARES?

• Consumers• Business

Community• Provider

Community• Payors• Advocacy Groups

WHO CARES?

Endorsed by…• The AAP, AAFP, ACP, and AOA,

representing approximately 333,000 physicians

• The Patient-Centered Primary Care Collaborative, representing employers, physicians, consumers and health plans

WHY IN OKLAHOMA?

• 2007 Summit Recommendation #9– Promote Patient-Centered Medical Homes

• 50th rank in health status improvement since 1990

• 43rd in PCP’s per 100,000 population– Oklahoma: 73 per 100,000– National median: 88 per 100,000

• Three of every five Oklahoma children (58.5 percent) do not have a medical home

What’s Been Done So Far?

• November 2007: CSG Joint Resolution– Endorses All State Legislatures to Promote the

PCMH

• March 2008: OK HCR 1058– Endorses PC-MH Principles

• May 2008: OK SB 1863– Encourages Legislative Study of the PC-MH

• May 2008: SB 1656 – PC-MH Task Force Formation

• November 2008: OHCA Medical Home Initiative

04/12/23 14

What is SoonerCare Choice What is SoonerCare Choice Today?Today?• SoonerCare Choice SoonerCare Choice is a managed is a managed

care model in which each care model in which each member is linked to a PCP who member is linked to a PCP who serves as their “medical home” serves as their “medical home”

• PCP’s manage the basic health PCP’s manage the basic health care needs, including after care needs, including after hours care and specialty referral hours care and specialty referral of the members on their panelof the members on their panel

OCHA MEDICAL HOME INITIATIVE

04/12/23 15

OHCA PCP OHCA PCP NetworkNetwork

• SoonerCare Choice has over 400,000 SoonerCare Choice has over 400,000 members enrolled statewidemembers enrolled statewide

• Over 1,000 PCP’s (up from 800+ in 2003)Over 1,000 PCP’s (up from 800+ in 2003)• Each PCP has a max panel of 2,500Each PCP has a max panel of 2,500• PA or APN PCP’s have a max panel of PA or APN PCP’s have a max panel of

1,2501,250• Average panel size - 300 members per Average panel size - 300 members per

PCPPCP


04/12/23 16

Who Can be a PCP Who Can be a PCP Today?Today?

CliniciansClinicians• General General

PractitionersPractitioners• Family PhysiciansFamily Physicians• Internal MedicineInternal Medicine• OB/GYNsOB/GYNs• PediatriciansPediatricians• Physician Physician

Assistants (PA)Assistants (PA)• Advance Practice Advance Practice

Nurses (APN)Nurses (APN)

Entity’sEntity’s• FQHC’sFQHC’s• RHC’sRHC’s• IHS IHS

FacilitiesFacilities


04/12/23 17

Medical Advisory Task Force Medical Advisory Task Force (MAT)(MAT)

• MAT was created February MAT was created February 2007 at “request of the 2007 at “request of the providers”providers”

• Representatives from Representatives from respective provider respective provider associationsassociations– OOAOOA– OSMAOSMA– OAFPOAFP– AAP, Oklahoma ChapterAAP, Oklahoma Chapter


04/12/23 18

Medical Advisory Taskforce Four Top Medical Advisory Taskforce Four Top PrioritiesPriorities

• Change in current payment Change in current payment structure structure

• Medical homeMedical home• Eliminate auto-assignmentEliminate auto-assignment• CredentialingCredentialing


Current SoonerCare Choice Current SoonerCare Choice

PaymentPayment Monthly capitated payment Monthly capitated payment

“bundles”:“bundles”:• Case Management / Care Coordination Case Management / Care Coordination

FeeFee• Primary care office visitsPrimary care office visits• Limited lab servicesLimited lab services

Other care paid on FFS basisOther care paid on FFS basis

Incentive PaymentsIncentive Payments• EPSDT / 4EPSDT / 4thth DTaP bonus DTaP bonus

04/12/23 19


04/12/23 20

Recommended PCMH Recommended PCMH PaymentPayment

• A monthly care coordination A monthly care coordination payment payment

• A visit-based fee-for-service A visit-based fee-for-service component component

• A performance-based componentA performance-based componentSource:Source: The Patient Centered Primary Care Collaborative The Patient Centered Primary Care Collaborative

http://www.patientcenteredprimarycare.org/

The most effective way to re-align The most effective way to re-align payment incentives to support the payment incentives to support the PCMH would be to combine PCMH would be to combine traditional fee-for-service for office traditional fee-for-service for office visits with a three part model that visits with a three part model that includes:includes:


http://www.patientcenteredprimarycare.org/

04/12/23 21

SoonerCare Choice Comparison

•Prepayment for case management Prepayment for case management onlyonly•Referrals only needed for specialty Referrals only needed for specialty carecare•Group contracts must designate a Group contracts must designate a medical directormedical director•Elimination of default auto-Elimination of default auto-assignmentassignment•Online provider enrollmentOnline provider enrollment

•Current funding remains the same Current funding remains the same •Provider determines medical Provider determines medical necessitynecessity•Federal restrictions (e.g. EMTALA, Federal restrictions (e.g. EMTALA, co-pays)co-pays)

What Stays the What Stays the Same?Same?

What Changes?What Changes?


04/12/23 22

Additional SoonerCare Choice Additional SoonerCare Choice ChangesChanges

• Coverage of new codes (e.g. after hours)Coverage of new codes (e.g. after hours)• OB/GYN that do not provide primary OB/GYN that do not provide primary

care may no longer be PCP’scare may no longer be PCP’s• Members may change PCP’s within the Members may change PCP’s within the

monthmonth• Case mgmt payment will be based on Case mgmt payment will be based on

date processeddate processed


SoonerCare Choice SoonerCare Choice DemographicsDemographics

04/12/23 23

84% are 84% are ChildrenChildren


SoonerCare Choice SoonerCare Choice Demographics, Cont’dDemographics, Cont’d

04/12/23 24

Estimated Percentage of Adults with Estimated Percentage of Adults with Chronic Conditions and Children with Chronic Conditions and Children with

Special Health Care NeedsSpecial Health Care Needs


Current PC Payment Current PC Payment StructureStructure

Capitated bundled rates include payment Capitated bundled rates include payment forfor::

• Monthly case management based on age/sex cellsMonthly case management based on age/sex cells– Weighted average = $2.23 pmpmWeighted average = $2.23 pmpm

• E&M Visits based on % of Medicare fee schedule E&M Visits based on % of Medicare fee schedule and actuarial based utilization assumptions and actuarial based utilization assumptions (somewhat higher than actual encounter data (somewhat higher than actual encounter data received)received)

04/12/23 25

Average total payment for physicians Average total payment for physicians = $30 pmpm= $30 pmpm


04/12/23 26

Proposed New SoonerCare Choice Proposed New SoonerCare Choice PaymentsPayments

• Monthly Case Mgt - Care Coordination FeeMonthly Case Mgt - Care Coordination Fee– Peer grouped by type of panel and capabilities of Peer grouped by type of panel and capabilities of

practicepractice

• Visit based componentVisit based component– Fee for serviceFee for service

• Expanded Performance Component Expanded Performance Component (SoonerExcell)(SoonerExcell)

• Transitional Payments in Year 1Transitional Payments in Year 1

““Unbundled” to incorporate PCMH Unbundled” to incorporate PCMH principlesprinciples


Medicare Medical Home Medicare Medical Home Demonstration eff. 1/1/09Demonstration eff. 1/1/09

•Tier 1Tier 1 Entry LevelEntry Level $31.18$31.18•Tier 2Tier 2 TypicalTypical $39.39$39.39•Tier 3Tier 3 AdvancedAdvanced $45.96$45.96Estimated care management fee based on RVS Update Estimated care management fee based on RVS Update Committee (RUC) RVU recommendations for practices Committee (RUC) RVU recommendations for practices that qualify as medical homes. Includes increased that qualify as medical homes. Includes increased cost for 1 nurse care managercost for 1 nurse care manager

04/12/23 27


Chronic conditions and the Chronic conditions and the Medicare populationMedicare population

04/12/23 28

Currently, 78% of the Medicare Currently, 78% of the Medicare population suffer from one or population suffer from one or more chronic conditions that more chronic conditions that require ongoing medical require ongoing medical managementmanagement

Gottlich. Partnership for Solutions, Medical Gottlich. Partnership for Solutions, Medical Necessity Determination in the Medicare Necessity Determination in the Medicare Program (January 2003)Program (January 2003)


Panel TypePanel Type– Children onlyChildren only– Adults and ChildrenAdults and Children– Adults OnlyAdults Only

ANDAND

Medical Home LevelMedical Home Level– Tier 1 = Entry Level Tier 1 = Entry Level

PCMHPCMH– Tier 2 = Tier 2 = StandardStandard PCMH PCMH– Tier 3 = Advanced PCMHTier 3 = Advanced PCMH

04/12/23 29

Case Management Case Management FeeFee


Care Coordination Fees for Care Coordination Fees for SoonerCare ChoiceSoonerCare Choice

Rates based on a blend of the:Rates based on a blend of the:– RUC recommendation for the Medicare RUC recommendation for the Medicare

chronic condition populationchronic condition population– Payment for Payment for generallygenerally healthy Medicaid healthy Medicaid

populationpopulation

04/12/23 30


04/12/23 31

Tier 1 Tier 1 RequirementsRequirements

1.Provides or coordinates all medically necessary primary/preventive services

2.Participates in VFC & OSIIS if serving children

3.Uses patient-specific charting system 4.Uses medication reconciliation

system5.Uses lab tracking & patient

notification system


04/12/23 32


6. Utilizes referral tracking system7. Provides care coordination &

continuity of care 8. Supports family participation in care

coordination9. Provides adm capability to obtain

specialty referrals10. Provides adm capability to obtain

prior auth’s11. Provides patient education and

support


04/12/23 33

Tier 1 Optional Tier 1 Optional Add-Ons

Must do both 1. Accepts electronic communication

from OHCA2. Provides 24/7 voice to voice

telephone coverage with immediate availability of an on-call medical professional


Tier 1 Care Mgt Payments Tier 1 Care Mgt Payments (pmpm)(pmpm)

Type of PanelType of Panel• Children Only = $3.58Children Only = $3.58• Children and Adults = $4.33Children and Adults = $4.33• Adults Only = $5.02Adults Only = $5.02

• Add-on payment = $0.55Add-on payment = $0.55

04/12/23 34


04/12/23 35


1. Obtains provider & patient MH role mutual agreement

2. Maintains a full-time practice (30 hrs appt/wk)

3. Uses scheduling processes that promote PCP continuity

4. Uses mental health & substance abuse screening & referral procedures


04/12/23 36

Tier 2 Tier 2 RequirementsRequirements5. Uses OHCA data to identify & track

MH patients both inside and outside of the PCP practice

6. Coordinates care & follow-up for MH patients from inpatient & outpatient facilities, as well as patient care outside of the PCP’s office

7. Implements processes to promote access & communication


04/12/23 37

Tier 2 Add-On Tier 2 Add-On OptionsOptions

Must Choose 3Must Choose 31. Develops a PCP-led practice team2. Provides after-visit follow up for the

MH patient3. Adopts EB clinical guidelines on

preventive & chronic care 4. Uses medication reconciliation to

avoid interactions or duplications


04/12/23 38

5. Provides care to voluntarily enrolled children who are in state custody

6. Uses SBIRT procedures to assess an individual’s behavioral health status

7. Participates in practice facilitation program

8. Provides 4 hours of after-hours care outside of 8am to 5pm, Monday - Friday

OCHA MEDICAL HOME INITIATIVETier 2 Add-On Tier 2 Add-On

OptionsOptionsMust Choose 3Must Choose 3

Tier 2 Care Mgt Payments Tier 2 Care Mgt Payments (pmpm)(pmpm)Type of PanelType of Panel• Children Only = $4.65Children Only = $4.65• Children and Adults = $5.64Children and Adults = $5.64• Adults Only = $6.53Adults Only = $6.53

• Add-on payment = $0.55Add-on payment = $0.55

04/12/23 39


04/12/23 40

Tier 3 RequirementsTier 3 Requirements

1. Organizes & trains staff in roles for care management2. Creates & maintains a prepared & proactive care team3. Provides timely call back to patients4. Adheres to EB clinical practice guidelines on preventive &

chronic care5. Uses health assessment to characterize patient needs &

risks 6. Documents patient self-mgt plan for those with chronic

disease7. Develops a PCP-led health care team8. Provides after-visit follow up for the MH patient


04/12/23 41

Tier 3 RequirementsTier 3 Requirements

9. Adopts specific EB guidelines10. Uses medication reconciliation to avoid interactions or

duplications11. Provides care to voluntarily enrolled children who are in state

custody12. Uses SBIRT procedures to assess an individual’s behavioral

health status13. Provides 4 hours of after-hours care outside of 8am to 5pm,

Monday – Friday14. Participates in practice facilitation program


04/12/23 42

Tier 3 Add-On OptionsTier 3 Add-On OptionsMust do all 3Must do all 3

1. Provides secure patient access system to personal health information

2. Uses integrated care plan to plan & guide patient care

3. Reports PCP performance to OHCA


Tier 3 Care Mgt Rates Tier 3 Care Mgt Rates (pmpm)(pmpm)Type of PanelType of Panel• Children Only = $6.19Children Only = $6.19• Children and Adults = $7.50Children and Adults = $7.50• Adults Only = $8.69Adults Only = $8.69

• Add-On Payment = $0.55Add-On Payment = $0.55

04/12/23 43


04/12/23 44

SoonerExcell SoonerExcell ComponentsComponents

• Child health exams (EPSDT) and 4th DTaP = $ 1.5 m• Generic drug prescribing = $ 0.5 m• Cervical cancer screenings = $ 0.3 m• Breast cancer screenings = $ 0.05

m• Physician inpatient admitting and visits = $ 0.85 m• ER utilization = $ 0.5 m


THE MASSACHUSETTS LESSON

1. Engage PCMH Task Force to study the OHCA initiated Medical Home proposal in addition to it’s legislative mandate

2. Implement the OHCA Medical Home proposal3. Explore using PCMH principles as a minimum

standard for state-licensed commercial health insurance products

4. Strengthen the PCP workforce in the state5. Promote education about and implementation of

of the Medical Home principles by the:– Health dept – General population– OID – Insurance companies– Provider associations (OSMA, OOA, OAFP, etc)– OHCA – SoonerCare members– OSEEGIB – their members– Insurance companies – their members

POTENTIAL RECOMMENDATIONS