the patient centered medical home in the information age ted epperly, m.d. program director and...

The Patient Centered Medical Home in the Information Age

Ted Epperly, M.D. Program Director and C.E.O.

Family Medicine Residency of IdahoClinical Professor of Family and Community Medicine

University of Washington School of MedicinePresident-Elect

American Academy of Family Physicians

Five Ages of Civilization

Hunter/Gatherer

Industrial

Agricultural

Wisdom

Information/Knowledge Worker

Failure to Embrace Family Medicine

Despite its 39-year history, neither the general public nor healthcare professionals understand all that Family Medicine represents.

“Strategic planning does not deal with future decisions. It deals with the futurity of present decisions. Decisions exist only in the present. The question that faces the strategic decision-maker is not what his organization should do tomorrow. It is: What do we have to do today to be ready for an uncertain tomorrow?”

-Peter Drucker

“Don’t skate to where the puck is, but where the puck will be.”

- Wayne Gretzky

The Future of Family Medicine Charge

“Develop a strategy to transform and renew the specialty of family practice to meet the needs of people and society in a changing environment.”

Simple Rules for the 21st Century Health Care System

Current Approach New Rules

Care is based primarily on visits

Care is based on continuous healing relationships

Professional autonomy drives variability

Care is customized according to patient needs and values

Professionals control care The patient is the source of control

Information is a record Knowledge is shared and information flows freely

Decision making is based on training and experience

Decision making is evidence-based

Source: Crossing the Quality Chasm: A New Health System for the 21st Century, Committee on Quality of Health Care in America, Institute of Medicine Washington, DC, USA: National Academies Press; 2001

Simple Rules for the 21st Century Health Care System

Current Approach New Rules

Do no harm is an individual responsibility

Safety is a system property

Secrecy is necessary Transparency is necessary

The system reacts to needs Needs are anticipated

Reduction in cost sought Waste is continuously decreased

Preference is given to professional roles rather than the system

Cooperation among clinicians is a priority

Source: Crossing the Quality Chasm: A New Health System for the 21st Century, Committee on Quality of Health Care in America, Institute of Medicine Washington, DC, USA: National Academies Press; 2001

Future of Family Medicine Ten Recommendations

1. New Model of Family Medicine2. Electronic Health Records3. Family Medicine Education4. Life Long Learning5. Enhancing the Science of Family Medicine6. Quality of Care7. Role of Family Medicine in Academic Health Centers8. Promoting a Sufficient Family Medicine Workforce9. Communications10.Leadership and Advocacy

Source:The Future of Family Medicine - Annals of Family Medicine - 2004

New Model of Family Medicine

• Personal Medical Home

• Patient-Centered Care

• Team Approach

• Elimination of Barriers to Access

• Advanced Information Systems

• Redesigned Offices

Source:The Future of Family Medicine - Annals of Family Medicine - 2004

New Model of Family Medicine (cont’d)

• Whole-Person Orientation

• Care Provided within a Community Context

• Emphasis on Quality and Safety

• Enhanced Practice Finance

• Commitment to Provide Family Medicine’s Basket of Services

Source:The Future of Family Medicine - Annals of Family Medicine - 2004

Medicine Work Force

300,000,000 Americans

900,000 Physicians

333:1 American/Physician

Number of Physicians Per Capita

020406080

100120140160180200220240260280300320

1900 1920 1940 1960 1980 2000

From Silver From Overpeck From AMA

Total physicians

FP/GP

AMA 2007

Total Number of Physicians – 902,053

Family Medicine Physicians – 80,809

Source: AMA Physicians Characteristics and Distribution 1980, 1990, 2000, Overpeck MD. Physicians in family practice 1931-67. Public Health Rep 1970; 85(6):485-494.

Which System is More Stable?

Why?

• Salary

• Lifestyle

• Increasing Medical School Debt

• Perceived Prestige

• Rising Overhead

• Unfunded Mandates

Median Compensation for Selected Medical Specialties

Data are from the Medical Group Management Association Physician Compensation and Production Survey, 1998 and 2005

$2,300,000,000,000

America’s Rankings

Source: Lebow R. Health Care Meltdown: JRI Press: 2002

#1 - Health Care Dollars Spent Per Capita

#1 - Health Care Technology

#1 - Research Dollars Spent Per Capita

#20 - Health Care Outcomes (e.g. life expectancy, infant mortality, and immunizations)

#37 - Health Care System

#54 - Fairness (tied with Fiji)

Starfield B. Is U.S. Health Really the Best in the World? JAMA 2000; 284(4):483-485.

Starfield B. Is U.S. Health Really the Best in the World? JAMA 2000; 284(4):483-485.

Rationale for the Benefits of Primary Care for Health

1. Greater Access to Needed Services

2. Better Quality of Care

3. A Greater Focus on Prevention

4. Early Management of Health Problems

5. Cumulative Effect of Primary Care to more Appropriate Care

6. Reducing Unnecessary and Potentially Harmful Specialist Care

Source: Starfield B., Leiyu S., Mackinko J., Contribution of Primary Care to Health Systems and Health, (Milbank Quarterly, Vol. 83., No. 3, 2005) 457-501)

Rationale of a Primary Health Care Based System

• Decreased Morbidity and Mortality• More Equitable Distribution of Health in

Populations• Lower Cost of Care• Better Self-Reported Health• Primary Care Physicians achieve Better

Outcomes than do Specialists at much Lower Costs

• Increasing the Number of Specialists is Associated with Lower Quality, Increased Cost, Increased Morbidity, and Increased Mortality

Source: Starfield B., Leiyu S., Mackinko J., Contribution of Primary Care to Health Systems and Health, (Milbank Quarterly, Vol. 83., No. 3, 2005) 457-501)

“Too many specialists are as dangerous to the quality and quantity of medical care in a community as too few.”

- Stanley R. Truman, M.D. President Elect AAGP September 13, 1949

Not Just a Change In Name…but a Change In Attitude!

AGGRESSIVE OPTIMISM!AGGRESSIVE OPTIMISM!

Bold

Champion

Five Pillars of Healthcare Change

• Patient Centered Medical Home

• Payment Reform

• Student Interest in Family Medicine

• Workforce Reform

• Healthcare for All

How Do We Change Our Health Care System?

Health Care for Everyone

• Medical Home

• No Financial Barriers for– Primary Care– Prenatal Care– Well Child Care– Immunizations– Evidence Based Preventive Services– Hospice Care

Health Care for Everyone (cont’d)

• The Individual will Share Financial Responsibility for:– Medications– Hospitalizations– Durable Medical Equipment– ED visits– Consultations and Referrals– Dx Tests and Procedures not

done in Medical Home– Long-Term Care

Health Care for Everyone (cont’d)

• How is this paid for?– Enhanced Fee for Service– P4R– P4P– CMF

• Care Management Fee– $15 PMPM

• Lewin Group– $8 Billion Cost to CMS but Saves $15 Billion/Year– $48 Billion Cost to Rest of U.S. but Save $83

Billion/Year– Saves $15.63 /Person Per Month

Health Care for Everyone (cont’d)

• The Type of Payment System Does Not Matter

• What Does Matter:– Primary Care Based System– Medical Home– Primary Care Physicians –

Integration/Coordination/Relationships– Higher Quality, Better Outcomes, More

Preventive Services, Improved Patient Satisfaction, Significantly Lower Costs

Joint Principles of the Medical Home (AAFP, ACP, AAP, AOA)

• Personal Physician

• Physician Directed Medical Practice

• Whole Person Orientation

• Care is Coordinated and Integrated

• Quality and Safety are Hallmarks

• Access is Enhanced

• Payment Reform

FamilyPhysician

PatientFamilies

Communities

Patient Centered Primary Care Collaborative (PCPCC)

1. Employers - 50 Million Plus

2. Consumer Groups - 47 Million Plus

3. Physician Groups - 330,000 Plus

4. Insurers – All of the Big Six

AARPAetna*American Academy of Family Physicians*American Academy of Pediatrics*American Board of Medical SpecialtiesAmerican College of Osteopathic Family PhysiciansAmerican Board of Medical SpecialtiesAmerican College of CardiologyAmerican College of Osteopathic InternistsAmerican College of Physicians*American Geriatrics SocietyAmerican Health Quality AssociationAmerican Heart AssociationAmerican Osteopathic Association*Aurum DxAutomotive Industry Action GroupBlueCross BlueShield Association*Bridges To ExcellenceThe Capital District Physicians’ HealthPlan, Inc.Carena, Inc.CaterpillarThe Center for Excellence in Primary CareThe Center for Health Value InnovationColorado Center for Chronic Care InnovationsCIGNA*CVS Caremark*§ CVS/pharmacy § Caremark Pharmacy Services § MinuteClinicDelmarva FoundationThe Department for Family and Community Medicine, University of California, San FranciscoDelphi CorporationDeseret MutualDMAA: The Care Continuum AllianceeHealth InitiativeThe ERISA Industry Committee*Exelon CorpFedEx CorporationFoundation for Informed Medical Decision MakingGeneral Mills, Inc.General Motors

Geisinger Health SystemsGlaxoSmithKlineHealth DialogHR Policy AssociationHumana, Inc.*IBM*Incenter StrategiesMcKesson CorporationMDdatacoreMedco*Medical Network OneMerck*MVP Health CareNational Association of Community Health CentersNational Business Group on HealthNational Business Coalition on HealthNational Coalition on Health CareNational Committee for Quality AssuranceNational Consumers LeagueNational Partnership for Women & FamiliesNational Retail FederationNew England Quality Care AllianceNew York City Department of Health and Mental Hygiene Novo NordiskThe Pacific Business Group on Health Partners In CarePfizer*Practice Transformation InstitutePudget Sound Health AllianceThe Roger C. Lipitz Center for Integrated Health Care at the Johns Hopkins Bloomberg School of Public HealthService Employees International UnionSociety of General Internal MedicineSociety of Teachers of Family MedicineThe Stoeckle Center at Massachusetts General Hospital UnitedHealthcare*United States SteelUniversity of Pittsburgh Medical Center Walgreens Health Initiatives*WellPoint, Inc.* WyethXerox

Updated 12/18/07

PPC-PCMH Scoring

Level of Qualifying

Points Must Pass Elements at

50% Performance Level

Level 3 75 -100 10 of 10

Level 2 50 – 74 10 of 10

Level 1 25 – 49 5 of 10

Not Recognized 0 – 24 < 5

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 do not Qualify.

NCQA Medical Home – 5 Musts• Has written standards for patient access and patient

communication;• Uses data to show it meets its standards for patient access and

communications;• Uses paper or electronic charting tools to organize clinical

information;• Uses data to identify important diagnoses and conditions in practice;• Implements evidence-based guidelines for al least three conditions;• Actively supports patient self-management;• Tracks tests and identified abnormal results systematically;• Tracks referrals using a paper-based or electronic system;• Measures clinical or service performance by physician or across the

practice;• Reports performance by physician or across the practice.

PayorsBuyers Providers

The Health Care Paradigm

Business Insurance

Companies

Physicians

Care Management Fee for PC-MHRVC Proposal to CMS

• Level 1 - $30

• Level 2 - $40

• Level 3 - $50

What Next?

• Advocacy

• Education

• Communication

• Payment Reform

• Politics / PAC

• Tipping Point?

Trim-Tab Leaders

“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”

- Margaret Mead

“The only limit to our realization of tomorrow will be our doubts of today, so let us move forward with strong and active faith.”

- Franklin D. Roosevelt

Summary

• Medical Home in the Information Age• Strategy to Transform and Renew• Future of Family Medicine – New Model• Basket of Services – Integrate and Coordinate• Primary Care Foundational to Health Care System• Medical Home and Designation• Payment Reform – Blended Rate• Workforce Reform• Patient Centered Primary Care Collaborative (PCPCC)• Health Care for Everyone

Patient Centered Medical Home in the Informational Age

Questions?