West Virginia wants PCMH Level Care

Paul Grundy MD, MPHIBM International Director Healthcare

Transformation

Trip to Denmark July 10 2009

Paul Grundy, MD, MPH, FACOEM, FACPM IBM Director Healthcare TransformationPresident Patient Centered Primary Care Collaborative

Who was Who was the the Shooter’s Doctor?Shooter’s Doctor?

Away from Away from Episodes of Care - Episodes of Care - FFS FFS

Population management !!

Accountability !!

If we truly want to understand costs and where they can be reduced without compromising outcomes, we need to aggregate costs around the patient. (need a place to do that – that is PCMH)

The way care is currently organized leads to redundant administrative costs, unnecessary and expensive delays in diagnosis and treatment, and unproductive time for physicians.

A system integrator a place where data is aggregated, understood and held accountable at the level of the individual patient -- THAT IS PCMH. In fact, cost reduction will often be associated with better outcomes.

The Big Idea: How to Solve the Cost Crisis in Health Careby Robert S. Kaplan and Michael E. Porter  Sept 2011 Harvard review

Just Out WellPoint End Of Pilots -- Rollout time for

PCMH!!! BCBS Mi 2670 physician (BIG study) CMS CMMI CPCi APC

2010 2011

Adults (18-64)

ER visits -6.6% -9.9%Primary care sensitive ER Visits -7.0% -11.4%Ambulatory care sensitive Hospitalizations (per 1,000) -11.1% -22.0%

The Cause? Mostly due to unregulated fee-for-service payments and an over reliance on rescue/specialty care. This is stark evidence that the U.S. health care Industry has been failing us for years “Commonly cited causes for the nation's poor performance are not to blame - it is the failure of the deliver system!!”

- Unaccountable Care Organizations* Peter A. Muennig and Sherry A. Glied Health Affairs Oct. 7, 2010

Dubuque, Iowa

WV 2011

76

88 8981

8899 97

109116

10697

134

115 113

127120

55 57 60 61 61 64 66 67 74 76 77 78 79 80 8396

0

50

100

150 1997–98 2006–07Deaths per 100,000 population*

U.S. Lags Other Countries: Mortality Amenable to Health Care

Source: Adapted from E. Nolte and M. McKee, “Variations in Amenable Mortality—Trends in 16 High-Income Nations,” Health Policy, published online Sept. 12, 2011.

The Bottom Line If the U.S. had achieved levels of amenable mortality seen in the three best-performing countries—France, Australia, and Italy—84,300 fewer people under age 75 would have died last year. Instead we focused on Rescue Care

The West Virginia Plan Strong Primary care is foundational to a high

performing healthcare system Additional resources needed to help primary care

manage populations Learned timely data is essential to success Learned must build better local healthcare systems

(public-private partnership) Physician leadership is critical Improve the quality of the care provided and cost

will come down

Sec of HHS Michael Lewis MD PhD Commissioner of Public Health, Marian Swinker, MD, MPH

WV HEALTH IMPROVEMENT INSTITUTEWV HEALTH IMPROVEMENT INSTITUTE

ADOPTION OFELECTRONIC

HEALTH RECORDS

Develop proposed mechanisms to

accelerate adoption of electronic health

records in West Virginia

MEASUREMENT

Create a forum of alignment of

measures across

stakeholders to facilitate reporting

SELF MANAGEMENT

SUPPORT

To align and improve access to resources

and best practices to improve the self-

activation capacity of all patients

EDUCATION OF THE PROVIDER

COMMUNITY

To develop a system of provider engagement to

accelerate Medicaid Transformation and

assist physician practices with migration

to AMH

PAY FORPERFORMANCE

To provide guidance on the deployment of a

P4P program as a model for the

State

QUALITYCOLLABORATIONS

To support a focused collaboration of key

stakeholders on improving quality, building on past

initiatives

Member EducationHealthy Rewards

Advanced Medical Homes

Advanced Medical HomesPay 4 Performance

Evidenced Based MedicineHealth Information Systems

Electronic Health InformationProvider Technology Incentives

OTHER RELEVANT INITIATIVESWV HIN – WVMI - OTHERS

Electronic Health RecordsElectronic Health Records

“A team approach to care…utilizing advanced information systems (including a standardized electronic health record); redesigned, more functional offices, and a whole-person orientation that focuses on quality, safety and care provided in a community context.”

129 Clinicians NCQA certified PCMH practices (ZERO Morgantown)

Advanced Medical HomeAdvanced Medical Home

Avoidable emergency room visits continue downward trend, seven percent better than market. Following evidence-based medicine continues to improve, six percentage points better than market. Medical cost trend is more than seven percentage points better than market. Diabetes is better controlled, will improve long-term health and lower medical costs.

And Today in West Virginia Medical Homes

Don’t handle your care needs in a BAD MEDICAL NEIGHBORHOOD!!

Unaccountable care, lack of organization, DO NOT GO THERE ALONE!!

Be wise when you pay for care, KNOW WHAT YOU BUY!! BEST HEART SURGERY !!!!

PopulationHealth

System Integrator

PatientExperience

The System Integrator

Creates a partnership across the medical neighborhood Drives PCMH primary care redesignOffers a utility for population health and Financial management

The Quadruple Aim = MU, PCMH & ACO Readiness, Experience of Care, Population Health, Cost

Per Capita Cost

Readiness

The Foundation for population health needs A long-term

comprehensive relationship with a Personal Physician empowered

with the right tools and linked to their care team.

The Joint Principles: Patient Centered Medical Home Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, and continuous and

comprehensive care Physician directed medical practice – the personal physician leads a team of

individuals at the practice level who collectively take responsibility for the ongoing care of patients

Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or arranging care with other qualified professionals

Care is coordinated and integrated across all elements of the complex healthcare community- coordination is enabled by registries, information technology, and health information exchanges

Quality and safety are hallmarks of the medical home- Evidence-based medicine and clinical decision-support tools guide decision-making; Physicians in the practice accept accountability voluntary engagement in performance measurement and improvementEnhanced access to care is available - systems such as open scheduling, expanded hours, and new communication paths between patients, their personal physician, and practice staff are used

Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home- providers and employers work together to achieve payment reform

If you scan the world for value based healthcare you will find a common element: a relationship-based team with a project manager! A comprehensivist that can command and control in an accountable system with DATA!!

So simple!So much!

Powerful Engine for transformation

Let me put this in WV

terms… Compressive vs Episodic

Integrated

Accessible

Coordinated

“Opportunities to expand access to primary care, build the health care workforce, and improve prevention and quality and attract jobs.”

Improve the care of the population while controlling costs

A “medical home” for patients, emphasizing primary care and make WV a business destination jobs .

Community networks capable of managing recipient care with local systems that improve management of chronic illness in both rural and urban settings

West Virginia Medicaid and employers –Valuebased purchasing means

holding providers accountable for both the quality and cost of care, through:

Increased transparency of cost and quality outcomes; Rewards for performance; and Payment reform. Emergency Department Collaborative Care

Management Initiative – Reduction ED Cost Accountable Communities Initiative -- align financial

incentives for those providers to work together to improve value and decrease avoidable costs.

Leveraging and/or expansion of current initiatives and federal opportunities

“Aug. 29 (Bloomberg) -- GlaxoSmithKline Plc is giving its privately insured U.S. workers PCMH level Care Via CCNC health-care network that uses primary care doctors to track patient use of specialists and hospitals.

Large Employers Partner With Medicaid CCNC

New Game Changer

Community Care North Carolina Patient-Centered Medical Home model. It provides a comprehensive, team-based model of healthcare delivery. This model drives out variability by implementing standards for all aspects of primary care services.

CCNC team ensures that care is all-inclusive and integrated with all other care provided within our system.

Each patient will be assigned to a Medical Home, led by one’s primary care physician. The patient is a part of that team as well as a nurse educator, a care coordinator, and other support staff , all linked into and supporting the patient’s health.

Reinventing Medicaid with PCMH findings are Outstanding Oklahoma's patient-centered medical home initiative has

reduced Medicaid costs $29 per patient per year from 2008 to 2010. Moreover, use of evidence-based primary care, including screening for breast and cervical cancer, increased.

The Colorado initiative expanded access to care. Before the initiative, only 20 percent of pediatricians in the state accepted Medicaid; as of 2010, 96 percent and did and at a lower cost to the state.

Vermont, inpatient care use and related per-person per-month costs decreased 21 percent and 22 percent, respectively, from July 2008 to October 2010. ER use and related per-person per-month costs decreased 31 percent and 36 percent, respectively. 

Patient Centered Medical Home in Washington in State Acute care spending there was 18 percent below the national average. Inpatient stays per beneficiary were 35 percent below the national average.

Citation -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results," Health Affairs, July 2011 30(7):1325–34.

The Bottom Line in Medicaid (AS WV discovered already) PCMH starting to show an impact in access to care, quality, and cost control.

8

Source: Health2 Resources 9.30.08

Defining the Care

Publically available

information

•Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs.

21

Medical Home Model

Patientis the center

of theMedical Home

Population Health

Patient-Centered Care

Refocused Medical Training

Patient & Physician Feedback

Advanced IT Systems

Access to Care

Team-Based Healthcare

Delivery

Decision Support Tools

Model adapted from theNNMC Medical Home

Enhances beneficiary’s relationship with provider

Includes all service primary care initiatives

Guiding principles, policy Certification criteria

(AHRQ modification) Governance

(formal/informal/advisory) Metrics

(process and end-state) Permits debut of the

“comprehensivist”

Enhancing Health andthe Patient Experience

Public Health Prevention

Specialists

PCMH in Action Vermont “Blueprint” model

Community Care TeamNurse Coordinator

Social WorkersDieticians

Community Health WorkersCare Coordinators

Public Health Prevention HEALTH WELLNESS

Hospitals

PCMH

PCMH

Health IT Framework

Global Information Framework

Evaluation Framework

Operations

A Coordinated Health System

Mental health

PCMH

Vermont Financial Impact

2009 2010 2011 2012 2013Percentage of Vermont population participating 6.7% 9.8% 13.0% 20.0% 40.0%

Participating population 42,179 61,880 82,332127,04

5254,852 # Community Care Teams 2 3 4 6 13

Smarter Healthcare…36.3% drop in hospital days,32.2% drop in ER use. 9.6%, total cost 10.5%, inpatient specialty care costs are down18.9%, ancillary costs down 15.0%. outpatient specialty down

Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US, K. Grumbach & P. Grundy, November 16th 2010.

Payment reform requires more than one method, you have dials, adjust them !!! MAINE IS !!

“fee for health”“fee for outcome”“fee for process,” “fee for

belonging/membership” “fee for service” “fee for satisfaction”

OPM $39 Billion Book with Accountable CarePatient at the center

24-7 clinician phone response Provide open scheduling. Provide care management and

coordination by specially-trained team members.

Use an EHR with decision support. Use CPOE for all orders, test

tracking, and follow-up. Medication reconciliation for every

visit. Prescription drug decision support. Implement e-prescribing.

Pre-visit planning and after-visit follow-up for care management.

Offer patient self-management support.

Provide a visit summary to the patient following each visit.

Maintain a summary-of-care record for patient transitions.

Email consultations. Telephone consultations. The development of care

plans. Performance outcome measures.

CMS New Comprehensive Primary Care Initiative

Risk-stratified care management: Primary care practices will be able to proactively assess their patients to determine their needs and provide appropriate and timely preventive care.

Access and continuity: Primary care practices must be accessible to patients on a 24/7 basis

Planned care for chronic conditions and preventive care

Patient and caregiver engagement:

Coordination of care across the medical neighborhood.

Where do you train the WV Workforce? There are examples of at least a few "high performing" Health

Professional schools that support team based coordinated care delivery SELECT AND SUPPORT THESE

…Requires a Smarter Healthcare Workforce

OR ?

Recommendations WVU and WV Start the journey -- build the foundation,

the horizontal platform, a place of accountability - PCMH

WV really engage your patients find out what they need and become very patient centered

Employers in WV Stop buying from unaccountable care organizations unwilling to transform - Join us

WV - Stop sending your students to train at UCO’s. Set up WV workforce standards for education and

training based on guiding principles of PCMH Integrate Health and Sick care GIVE US LEADERSHIP ----SHOW US THE WAY