Medicaid PCMHLonnie Robinson, MD, FAAFPArkansas Academy of Family Physicians

Regional Family Medicine

Beth Milligan, MD, FAAFPArkansas Foundation for Medical Care

Saline Med-Peds

Sheena Olson, JDAssistant Director of Medical Services

Arkansas Medicaid

Overview• PCMH Background/Context• My PCMH Experience• Medicaid PCMH Requirements• Questions and Answers

Alternative Titles• Practical PCMH• DIY PCMH• “PCMH for the workin’ doc” • PCMH: Yeah, right!• PCMH: All theory, no (green) substance?• PCMH: Why are we still talking about this?• PCMH: Why it (still) matters

Why before How

“He who has a why to live for can bear almost any how.” -Nietzche

Why PCMH?• Increasing healthcare costs, percentage of GDP• Poorer health outcomes• Patient lifestyle/low engagement in care• Increasing understanding of the value and ROI

from primary care• Failure of FFS model (incentivize disease and

intervention over prevention and wellness)• Burden of chronic disease• Momentum from big business…

Personal Health CostsMedical CarePharmaceutical costsWorkers’ Compensation Costs

Productivity Costs

Presenteeism OvertimeTurnover

Temporary StaffingAdministrative Costs

Replacement TrainingOff-Site Travel for Care

Customer DissatisfactionVariable Product Quality

Absenteeism Short-term Disability Long-term Disability

Frustration with poor health -- both employers and employees

Iceberg of Additional Costs to Employers from

Poor Health

Sources: Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study", JOEM.2009; 51(4):411-428. and Edington DW, Burton WN. Health and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental Medicine. 3rd edition. Philadelphia, PA. Lippincott, Williams and Wilkens; 2003: 40-152

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Why PCMH is important for Family Physicians…

• Primary care is receiving a LOT of attention in the health care debate

• The era of value-based purchasing means there is a new normal arriving

• Fee For Service with no accountability is becoming a thing of the past

• Change is coming…change or die!• You don’t want to be the slowest antelope• Most Important: it’s the right thing for our

patients!

Paralyzed by Confusion

Embracing the Opportunities

Happily Existing in

Denial

Resigned to Acceptance

UnderstandingLower Greater

Greater

Lower

Resiliency

Leadership is needed: The Four Camps of Health Organizations

Arkansas is leading!• Medicaid PCMH• Comprehensive Primary Care Initiative• Private Payer Projects (forthcoming)

Leadership: “Pissing people off at a rate

they can absorb…”

Marci Nielsen, PhD, MPHCEO, Patient Centered Primary Care Collaborative

“If you always do what you always did, you will always get

what you always got.”

- Albert Einstein

Cowboys vs. Pit Crews

Atul Gawande, MD, MPH• Harvard Professor, Surgeon, Writer• Public Health Researcher• Speech at Harvard, 2011

– “We train, hire and pay physicians to be cowboys…”• The Lone Ranger

– “…Instead, we should be training them to be like Pit Crews.”

• Focused on teamwork, disciplined, data-driven, standardized

• Also credited with “Triple Aim…Plus One”

Quadruple Aim / Triple Aim + One

Reduced Costs

Improved Outcome

Patient Sat-isfaction

Physician Satisfac-

tion

PCMH “Need to Knows”

Dr. Jonathan Sugarman, Qualis HealthAAFP Annual Leadership Focus

May 2, 2014

PCMH “Need to Knows…”

• Despite the short half-life of many health policy innovations (buzz words), medical homes continue to capture the attention of key stakeholders

• PCMH’s are living up to expectations*• The payment landscape is changing in a

positive way

*Depending on whom you ask!

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The Hype Cycle: Waves of Irrational Exuberance

Time

Expectations

Real Progress

Trigger Peak of Inflated

Expectations

Trough of Disillusionment

Slope of Enlightenment

Plateau of Productivity

Adapted from Gartner Research

Medical Homes?

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Are PCMH’s living up to expectations?It depends on whom you ask…

18

Feb. 25, 2014

"There are folks who believe the medical home is a

proven intervention that doesn't even need to be

tested or refined. Our findings will hopefully change

those views," said Mark W. Friedberg, a researcher

at RAND Corp. and lead author of the study,

published Tuesday in the Journal of the American

Medical Association.

(Friedberg et al. JAMA. 2014;311(8):815-825).

Response to JAMA article• “A practice could be a PCMH without achieving

certification and achieving certification does not necessarily mean that a practice is functioning as a PCMH”

• The study group received financial incentives for NCQA certification but not for controlling costs

• No after hours or extended hours• No targeting of high risk populations• Missing key features: patient-centeredness, team-

based care, and behavioral health integration• Authors response ignored results from bulk of previous

data

States with Medicaid/CHIP Medical Home Activity Since 2006

States with an Active Role in a Multi-Payer Medical Home Initiative

Medicaid PCMH

• Minimum 300 ConnectCare Medicaid Patients• Beginners welcome…No certification required • Practice Support: Qualis, AFMC• Must meet milestones, achieve metrics• Reimbursement via Alternative Payment Model:

– PMPM payments (average: $4)– Continued FFS for encounters as previously– *Opportunity to participate in “shared savings”

*Must meet eligibility requirements

Regional Family Medicine

• Formerly Kerr Medical Clinic• 8 physicians, 3 APNs, 50+ employees, • 2 locations• Inpatient / Outpatient / Obstetrics• Lab / Radiology• 27,000+ active patient charts• EHR: e-MD’s (April 2012)• MU/PQRS attested

RFM PCMH Journey• Launched e-MD’s April 2012• Applied CPCi June 30, 2012• Attested Stage I MU mid-July 2012• Formed PCMH Transformation Team • Enrolled Medicaid PCMH• January: first PMPM payment!• Pooled for shared savings with pediatric

practice in Jonesboro

RFM: Existing PCMH Characteristics

• Physician-based teams with “care coordinator”

• 24/7 live voice access• Extended office hours: Saturday• ER, hospitalization avoidance • Dr. Robert Kerr: “The Answer is ‘Yes’…”

RFM Changes• Initial:

– Identification of High Risk Patients– “Care Coordinator”– Patient notification (text)– Care Plan (“Well-written SOAP Note”)– Documentation of same day appt requests

• Upcoming/Ongoing: – Formal Quality Improvement Process– Patient Portal– SHARE– Formal Policy & Procedures– Optimizing EMR to perform key PCMH functions

PCMH Challenges• Organizational structure, inertia, momentum• Culture change (team-based care mind set)• Documentation• Overcoming Lingo/Jargon Gap• Leveraging technology• Doing all of the above in a traditionally high-

volume practice (“Just one more thing, Doc…”)• Payer Issues (comprehensive participation,

data mistrust)

Bottom Line• PCMH ain’t going away

– FFS as sole means of compensation is (rapidly?) becoming a thing of the past

– Value-Based Purchasing is becoming the new normal• Medicaid PCMH: great way to start process

– PMPM’s to assist in beginning processes– Continued FFS for episodic/acute care– Opportunity for shared savings– Practice support from AFMC, Qualis– Prepares your practice for other opportunities,

aligns with other incentives (MU, PQRS, etc.)

Medicaid PCMH Requirements

Dr. Beth Milligan, MD, FAAFPArkansas Foundation for Medical Care

Saline Med-Peds

Patient Centered Medical HomeBuilding a healthier future for all Arkansans

Health Care Payment Improvement Initiative

Reinvigorate Primary Care

Current state Future through PCMH

(citizen)

Does not have a provider accountable for his care Has difficulty navigating the system

Triple Aim:

Improve health of population

Enhance patient experience

Reduce or control cost of care

(PCP)

Lower income than specialist peers Not currently using EMR but considering Gets little information from hospitals and ER’s about patients

Reinvigorate:

Increase PCP’s revenue and take-home pay

Improved practice processes and workflows

Empowered PCP central to the management of quality and cost of care across the health system

Purpose

Our aim is to create a

Sustainable patient-centered health systemthrough an evidence-based approach to care delivery

Population-based care delivery systemEpisode-based care delivery

Triple Aim AccountabilityImprove the health of the populationEnhance patient experience of care

Reduce or control cost of care

Process

Commitment to transform the systemState launches PCMH

Providers enroll

Support for providersFramework for change

Financial support for care coordinationTechnical expertise and vendor support

Transparency into performance

Incentives for quality and costQuality metrics ensure provision of appropriate care

Shared savings incentives encourage management of cost of care

Enrollment/Eligibility

PCMH Participation & EligibilityPCPs enrolled in ConnectCare

Must have at least 300 beneficiariesMeet participating practice definition (Section 200.000 proposed PCMH manual)

May not participate in the PCCM Shared Savings Pilot

To Enroll:

Provider Portalwww.paymentinitiative.org

Open Enrollment through December 15January 1 through May 15, 2014

VoluntaryPractice Participation Agreement

Annual re-enrollment

Enrollment/Eligibility

Shared Savings:Incentive payments made to a shared savings entity for delivery of economic, efficient and quality

care that meets the requirements of Section 232.000

Minimum of 5,000 Medicaid beneficiaries who have been attributed for at least 6 months

Single practice or by pooling attributed benes across more than one practice (up to 2 practices per entity 2014)

Practice Support:Section 241.000 – 242.000

Shared Savings Criteria

First Performance PeriodJanuary 1, 2014

Single practice or by pooling attributed benes across more than one practice (up to 2 practices per entity 2014)

If two practices, they must agree to measure performance togetherNo default pool

Second Performance PeriodTwo practice limit for pools is removed

Default poolMust be part of a shared savings entity to participate in PCMH

Benefits

Providers will receive practice supportCare Coordination

Monthly paymentsTechnical expertise

Practice TransformationOption to utilize DMS vendor support

Quarterly performance reports

Shared SavingsReward high quality care and cost efficiency

Enrollment

Enrollment