Edwina Rogers

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Patient Centered Primary Care Collaborative

• Edwina Rogers
• Executive Director
• Patient Centered Primary Care Collaborative
• 601 Thirteenth St., NW, Suite 400 North
• Washington, D.C. 20005
• Direct 202.724.3331
• Mobile [phone]
• erogers_at_pcpcc.net

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• Overview of Activity
• 27 Multi-stakeholder Pilots in 18 States
• 8 State Medicare Pilots Planned for 2009
• 44 States and the District of Columbia Have
  Passed over 330 Laws and/or Have PCMH Activity

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Blue Cross Blue Shield Plan Pilots (as of
January 2009)
Pilots in planning phase for 2009 implementation
Pilots in progress
Pilot activity in early stages of development
Multi-Stakeholder demonstration
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Some New 2009 Single-Payer Health Plan
Demonstration Pilots

• Key PCMH Pilot Programs Either in Place or in
  Development
• Cigna PCMH Pilot in New Hampshire
• Aetna has PCMH Pilots in
• Colorado
• Maine
• Mid-Hudson Valley
• Pennsylvania
• Central New Jersey
• Priority Health PCMH Pilot Program in Michigan
• Wellpoint, Inc. PCMH Pilot in New York City
• UnitedHealth Medical Home Pilot in Arizona
  (Tucson Phoenix)
• Blue Cross Blue Shield PCMH Pilot in Nebraska in
  early stages of development

New Demonstration Pilots Taking Place or in the
Process of Being Enacted
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State Initiatives to Advance Medical Homes in
Medicaid/SCHIP
Identified to have a medical home initiative
Source National Academy for State Health Policy
State Scan, November 2008
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Patient-Centered Medical Home 2009 Overview of
Pilot Activity and Planning Discussions
RI
Multi-Payer pilot discussions/activity
Identified pilot activity
No identified pilot activity 6 States
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Overview of the PCPCC

• We are now in our 4th year.
• Over 650 signing members
• Advancing the Patient Centered Medical Home
  (PCMH) concept in the public and private sectors
• Hosting Meetings, Summits and Congressional
  Briefings
• Weekly Call Thursday at 1100 AM EST
• Call-in Number 712.432.3900
• Passcode 471334
• Weekly Center calls established to
  operationalize work of PCPCC

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History of the Medical Home Concept

• The first known documentation of the term
  medical home Standards of Child Health Care,
  AAP in 1967 by the AAP Council on Pediatric
  Practice -- medical home -- one central source
  of a childs pediatric records History of the
  Medical Home Concept Calvin Sia, Thomas F.
  Tonniges, Elizabeth Osterhus and Sharon Taba
  Pediatrics 20041131473-1478
• Patient Centered IOM
• I would strongly urge the adoption of the Danish
  model of the Patient Centered Medical Home --
  Karen Davis Commonwealth Fund
• 2009 Medical Home Wikipedia page
  http//en.wikipedia.org/wiki/Medical_home

Henrik Jensen
Niels Rossing M.D.
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Collaborative Principles

• The Patient Centered Primary Care Collaborative
  is a coalition of major employers, consumer
  groups, patient quality organizations, health
  plans, labor unions, hospitals, clinicians and
  many others who have joined together to develop
  and advance the patient centered medical home.
  The Collaborative believes that, if implemented,
  the patient centered medical home will improve
  the health of patients and the viability of the
  health care delivery system. In order to
  accomplish our goal, employers, consumers,
  patients, clinicians and payers have agreed that
  it is essential to support a better model of
  compensating clinicians.
• Compensation under the Patient-Centered Medical
  Home model would incorporate enhanced access and
  communication, improve coordination of care,
  rewards for higher value, expand administrative
  and quality innovations and promote active
  patient and family involvement. The
  Patient-Centered Medical Home model will also
  engage patients and their families in positive
  ongoing relationships with their clinicians.
  Further, the Patient-Centered Medical Home will
  improve the quality of care delivered and help
  control the unsustainable rising costs of
  healthcare for both individuals and
  plan-sponsors.
• If you agree, please visit us at www.pcpcc.net
  and join today!

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The Patient-Centered Primary Care Collaborative
Examples of Broad Stakeholder Support
Participation
Providers 333,000 primary care
Purchasers Most of the Fortune 500

• ACP

• AAP

• IBM

• Ohio

• AAFP

• AOA

• Iowa

• FedEx

• General Electric

• ABIM

• ACC

• Dow

• ACOI

• AHI

• Business Coalitions

The Patient-Centered Medical Home

• Microsoft

• Merck Co.

80 Million lives
Payers
Patients

• AARP

• AFL-CIO

• BCBSA

• Aetna

• National Consumers League

• United

• Humana

• CIGNA

• Kaiser Permanente

• SEIU

• Foundation for Informed Decision Making

• WellPoint

• Geisinger

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Patient Centered Primary Care Collaborative
Four Centers - Over 770 volunteer members

• Center for Multi-Stakeholder Demonstration
  Identify community-based pilot sites in order to
  test and evaluate the concept offer hands-on
  technical assistance, share best practices, and
  identify funding sources to advance adoption.
• Center to Promote Public Payer Implementation
  Assist state Medicaid agencies and other public
  payers as they implement and refine programs to
  embed the Patient Centered Medical Home model by
  offering technical assistance sharing best
  practices and giving guidance on the development
  of successful funding models.
• Center for Health Benefit Redesign and
  Implementation Create standards and buying
  criteria to serve as a guide and tool for large
  and small employers/purchasers in order to build
  the market demand for adoption of the Medical
  Home model.
• Center for eHealth Information Adoption and
  Exchange Evaluate use and application of
  information technology to support and enable the
  development and broad adoption of information
  technology in private practice and among
  community practitioners.

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Joint Principles of the PCMH (February 2007)

• The following principles were written and agreed
  upon by the four Primary Care Physician
  Organizations the American Academy of Family
  Physicians, the American Academy of Pediatrics,
  the American College of Physicians, and the
  American Osteopathic Association.
• Principles
• Ongoing relationship with personal physician
• Physician directed medical practice
• Whole person orientation
• Coordinated care across the health system
• Quality and safety
• Enhanced access to care
• Payment recognizes the value added

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Endorsements

• The PCMH Joint Principles have received
  endorsements from 18 specialty health care
  organizations
• The American Academy of Chest Physicians
• The American Academy of Hospice and Palliative
  Medicine
• The American Academy of Neurology
• The American College of Cardiology
• The American College of Osteopathic Family
  Physicians
• The American College of Osteopathic Internists
• The American Geriatrics Society
• The American Medical Directors Association
• The American Society of Addiction Medicine
• The American Society of Clinical Oncology
• The Society for Adolescent Medicine
• The Society of Critical Care Medicine
• The Society of General Internal Medicine
• American Medical Association
• Association of Professors of Medicine
• Association of Program Directors in Internal
  Medicine
• Clerkship Directors in Internal Medicine
• Infectious Diseases Society of Medicine

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Defining the Medical Home
Source Health2 Resources 9.30.08
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PCPCC Payment ModelMay 2007
Key physician and practice accountabilities/
value added services and tools
Proactively work to keep patients healthy and
manage existing illness or conditions
Incentives
Coordinate patient care among an organized team
of health care professionals
Incentives
Performance Standards
Utilize systems at the practice level to achieve
higher quality of care and better outcomes
Incentives
Focus on whole person care for their patients
(including behavioral health)
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Evidence of Cost Savings quality improvement

• Barbara Starfield of Johns Hopkins University
• Within the United States, adults with a primary
  care physician rather than a specialist had 33
  percent lower costs of care and were 19 percent
  less likely to die.
• 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.
• Commonwealth Fund has reported
•  A medical home can reduce or even eliminate
  racial and ethnic disparities in access and
  quality for insured persons.
• Denmark has organized its entire health care
  system around patient-centered medical homes,
  achieving the highest patient satisfaction
  ratings in the world. Denmark has among the
  lowest per capita health expenditures and highest
  primary care rankings.
• Center for Evaluative Clinical Sciences at
  Dartmouth, states in the US relying more on
  primary care have
• lower Medicare spending,
• lower resource inputs,
• lower utilization, and
• better quality of care.

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Evidence of cost Savings Quality Improvement
This briefing document summarizes key findings
from recent PCMH evaluation studies. Across these
diverse settings and patient populations,
evaluation findings consistently indicate that
investments to redesign the delivery of care
around a primary care PCMH yield an excellent
return on investment Quality of care, patient
experiences, care coordination, and access are
demonstrably better. Investments to strengthen
primary care result within a relatively short
time in reductions in emergency department visits
and inpatient hospitalizations that produce
savings in total costs. These savings at a
minimum offset the new investments in primary
care in a cost-neutral manner, and in many cases
appear to produce a reduction in total costs per
patient.
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Simple Cost Avoidance
NC Savings (FY04)
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Patient-Centered Medical Home Team
ApproachBehavioral Health Needs in Primary Care
Practice

• 84 of the time, the 14 most common physical
  complaints have no identifiable organic etiology1
• 80 with a behavioral health disorder will visit
  primary care at least 1 time in a calendar year2
  67 with a behavioral health disorder do not
  get behavioral health treatment3
• 50 of all behavioral health disorders are
  treated in primary care3
• 48 of the appointments for all psychotropic
  agents are with a non-psychiatric primary care
  provider4
• 30-50 of referrals from primary care to an
  outpatient behavioral health clinic dont make
  first appt5.6
• Two-thirds of primary care physicians (N6,660)
  reported not being able to access outpatient
  behavioral health for their patients. Shortages
  of mental health care providers, health plan
  barriers, and lack of coverage or inadequate
  coverage were all cited by PCPs as important
  barriers to mental health care access7
• 6. Hoge et al., JAMA. 2006951023-1032. 7.
  Cunningham, Health Affairs. 2009 3w490-w501.

1. Kroenke Mangelsdorf, Am J Med.
198986262-266 2. Narrow et al., Arch Gen
Psychiatry. 1993505-107 3. Kessler et al.,
NEJM. 20063532515-23 4. Pincus et al., JAMA.
1998279526-531 5. Fisher Ransom, Arch Intern
Med. 19976324-333
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Patient-Centered Medical Home Cost of Unmet
Behavioral Needs

• Healthcare use/costs twice as high in diabetes
  and heart disease patients with depression1

• Untreated mental disorders in chronic illness is
  projected to cost commercial and Medicare
  purchasers between 130 and 350 billion
  annually2
• Approximately 217 million days of work are lost
  annually to related mental illness and substance
  use disorders (costing employers 17
  billion/year)2
• Depression treatment in primary care - 3,300
  lower total health care cost over 48 months3

1. Original source data is the U.S. Dept of HHS
the 2002 and 2003 MEPS. AHRQ as cited in
Petterson et al. Why there must be room for
mental health in the medical home (Graham Center
One-Pager) 2. Hertz RP, Baker CL. The impact of
mental disorders on work. Pfizer Outcomes
Research. Publication No P0002981. Pfizer 2002
3. Unützer et al., American Journal of Managed
Care 20081495-100.
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Whole Person Orientation System Integration and
Transformation Needed
Behavioral Health is an Inseparable Part of
General Medical Health

• Matching Physical and Mental Health Services to
  Patient Needs through
• Co-located and fully integrated physical mental
  health personnel
• OR
• Tightly coordinated mental physical health
  services
• Common mental physical health documentation
  system
• Unified outcomes analysis

Physical Illness
Mental Health Substance Use Disorders
Note Stand alone mental health services could
be paid for from the general medical budget, much
as stand alone rehabilitation, eye, and cardiac
services
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Kathol, 2009
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At least 14 Independent Evaluations in 11 States
. . . And Growing
RI
CMS will select 8 states for the Medicare Medical
Home Demonstration
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Several PCMH Evaluations Underway

• Approximately 14 independent evaluations
  represented in the PCMH Evaluators Collaborative
  (other evaluators are welcome to participate)
• The evaluations are examining a breadth of
  demonstrations
• From one payer to multi-payer pilots
• Involve anywhere from 5-70 primary care practices
  with 28-250 clinicians
• Include 27,000 -- 1,000,000 beneficiaries
• Many include safety net centers, pediatric sites
  and Medicaid as a payer
• Variety of payment models (hybrid, PMPM, annual
  comprehensive PC fee)
• All have the evaluations have comparison groups
• Key Questions Under Investigation
• What does it take to become a medical home?
• Do PCMHs improve
• Clinical Quality?
• Patients Experiences?
• Physician/Staff Experience?
• Efficiency?
• Is this sustainable/ are practices financially
  stable?

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NCQA PPC-PCMH Content and Scoring
Must Pass Elements
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NCQA PPC-PCMH Scoring
Levels If there is a difference in Level
achieved between the number of points and Must
Pass, the practice will be awarded the lesser
level for example, if a practice has 65 points
but passes only 7 Must Pass Elements, the
practice will achieve at Level 1. Practices with
a numeric score of 0 to 24 points or less than 5
Must Pass Elements are not Recognized.
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Meaningful Use Meaningful Connections

• Defines health IT capabilities essential to PCMH.
• Crosswalks capabilities with functional
  priorities supporting PCMH.
• Explores how patients/consumers are currently
  using health IT to connect.
• Representative sample of 19 case example
  responses from primary care providers.
• Appendices include
• Guidelines for PCMH Demonstration Projects
• Consumer Principles
• Consumer Toolkit

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Patient Centered Primary Care CollaborativePurch
aser Guide Released July, 2008

• Developed by the PCPCC Center for Benefit
  Redesign and Implementation in partnership with
  NBCH and the Centers multi-stakeholder advisory
  panel.
• Guide offers employers and buyers actionable
  steps as they work with health plans in local
  markets - over 6000 copies downloaded and/or
  distributed.
• Includes contract language, RFP language and
  overview of national pilots.
• Includes steps employers can take to involve
  themselves now in local market efforts.
• The PCPCC is holding a series of Webinars,
  sponsored by Pfizer, on the Purchaser Guide.

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Patient Centered Primary Care CollaborativeProof
in Practice A Compilation of Patient Centered
Medical Home Pilot and Demonstration Projects
Released October 2009

• Developed by the PCPCC Center for
  Multi-stakeholder Demonstration through a grant
  from AAFP offering a state-by-state sample of key
  pilot initiatives.
• Offers key contacts, project status,
  participating practices and market scan of
  covered lives physicians.
• Inventory of recognition program used, practice
  support (technology), project evaluation, and key
  resources.
• Begins to establish framework for program
  evaluation/ market tracking.

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Patient Centered Primary Care CollaborativeA
Collaborative Partnership Resources to Help
Consumers Thrive in the Medical Home Released
October 2009
Included in the Guide 1. PCPCC activities and
initiatives supporting consumer engagement 2.
Research and examples surrounding consumer
engagement in PCMH demonstrations 3. Tools for
consumers and other stakeholders to assist with
PCMH education, engagement and partnerships
and 4. A catalogue of resources that provides
descriptions of and the means to obtain potential
resources for consumers, providers and purchasers
seeking to better engage consumers.
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Information Flow- Consumer Materials
Four minute video for waiting room viewing
deep-dive on PCMH (Flash)
Promotes Primary Care (brochure)
Deep-dive focus on PCMH (brochure)
What consumers can expect- PCMH consumer
principles (brochure)
Guidance to create your own practice brochure in
support of PCMH model (paper)
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Inclusion of the Medical Home Concept in Health
Reform Efforts
Employer Trade Associations
Think Tanks
Executive Branch
The Patient-Centered Medical Home
Plans developed by Congressional
Representatives
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MEDICARE-MEDICAID ADVANCED PRIMARY CARE
DEMONSTRATION INITIATIVE

• On September 16, 2009 HHS Secretary Sebelius,
  along with Director of White House Office of
  Health Reform Nancy-Ann DeParle and Vermont
  Governor Jim Douglas, announced that the Centers
  for Medicare and Medicaid Services (CMS) will
  establish a demonstration program that will
  enable Medicare to join Medicaid and private
  insurers in innovative state-based advanced
  primary care initiatives.
• New Medicare Demonstration
• Design will include mechanisms to assure it
  generates savings for the Medicare trust funds
  and the federal government
• Private insurers work in cooperation with
  Medicaid to set uniform standards for Advanced
  Primary Care (APC) models
• Provide incentives for doctors to spend more time
  with their patients and offer better coordinated
  higher-quality medical care
• States Wishing to Participate in the New
  Demonstration Must
• Certify they have already established similar
  cooperative agreements between private payer and
  their Medicaid program
• Demonstrate a commitment from a majority of their
  primary care doctors to join the program
• Meet a stringent set of qualifications for
  doctors who participate and
• Integrate public health services to emphasize
  wellness and prevention strategies.

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PCMH - HOUSE of representatives activity

• The House Tri-Committee Health Reform Proposal
• Funding of 350 million for PCMH Pilot
  Programs, which include Independent PCMHs and
  Community-based Medical Homes.
• 'The Secretary shall establish a medical home
  pilot program (in this section referred to as the
  pilot program) for the purpose of evaluating
  the feasibility and advisability of reimbursing
  qualified patient-centered medical homes for
  furnishing medical home services (as defined
  under subsection (b)(2)) to high need
  beneficiaries (as defined in subsection
  (b)(1)).' 
• Medical Home Pilot Program for Medicaid.
  Establishes a 5-year pilot program to test the
  medical home concept with high-need Medicaid
  beneficiaries. The federal government would match
  costs of community care workers at 90 for the
  first two years and 75 for the next 3 years, up
  to a total of 1.235 billion.
• Payment incentive for selected primary care
  services. Increases the Medicare payment rate by
  5 for primary care services of physicians
  specializing in primary care. Eligible
  practitioners practicing in health professions
  shortage areas receive an additional 5.

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PCMH - Senate Activity

• Senate HELP Committee
• Grants to Establish Community Health Teams to
  Support a Medical Home Model the Secretary of
  HHS would establish a grant program to creating
  the community health team which is
  community-based, multi disciplinary,
  interprofessional teams (on the model of medical
  home) to increase access to comprehensive
  coordinated care.
• Enhancing Health Care Workforce Education and
  Training -. Priority is given to programs that
  educate students in team-based approaches to
  care, including the patient-centered medical
  home. Authorization is set at 125 million.
• Health Literacy and Shared Decision Making.
• Senate Finance Committee
• Create a new Medicaid state plan option where
  enrollees with at least two chronic conditions,
  or those with one chronic condition who are at
  risk of developing another chronic condition,
  could designate a provider as their health home.
  Qualifying providers would have to meet certain
  standards established by the Secretary.
• Require the Secretary to create a CMS
  Innovation Center, a new office authorized to
  test, evaluate, and expand different payment
  structures and methodologies that aim to foster
  patient-centered care, improve quality, and slow
  the rate of Medicare cost growth.
• Provide a new ten percent bonus for certain
  primary care practitioners beginning January 1,
  2011.
• Provide Medicare direct and indirect Graduate
  Medical Education funding for Teaching Health
  Centers.

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Upcoming Collaborative Events

• Tuesday, March 30, 2010 - Washington D.C.,
  Stakeholder Meeting - Ronald Reagan Building and
  International Trade Center
• Thursday, July 22, 2010 - Washington D.C.,
  Stakeholder Meeting - Ronald Reagan Building and
  International Trade Center
• Thursday, October 21, 2010 - Washington D.C.,
  Annual Summit - Ronald Reagan Building and
  International Trade Center

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• www.pcpcc.net
• About the PCPCC
• History
• Members
• Brochure
• Executive Committee
• Advisory Board
• Officers
• Executive Bios
• The Patient Centered Medical Home
• Joint Principles
• Endorsements by Specialists
• Employer Perspectives
• Evidence of Quality
• Health Reform Proposal
• Reimbursement Model

• Collaborative Centers
• Center to Promote Public Payer Implementation
• Center for Multi-Stakeholder Demonstration
• Center for Benefits Redesign and Implementation
• Center for eHealth Information Exchange and
  Adoption
• Other PCMH Resources
• Pilot Project Guide
• Purchasers Guide
• Evidence Documents
• Consumer Materials
• Events
• National Weekly Call
• Thursday, 1100AM EST

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Contact Information

• Visit our website http//www.pcpcc.net
• To request any additional information on the PCMH
  or the Patient Centered Primary Care
  Collaborative please contact
• Edwina Rogers
• Patient Centered Primary Care Collaborative
• Executive Director
• 202.724.3331
• 202.674.7800 (cell)
• erogers_at_pcpcc.net
• The Homer Building
• 601 Thirteenth St., NW, Suite 400 North
• Washington, DC 20005