Patient Centered Medical Home (PCMH)Performance Measures

May 2012

Office of the Chief Medical OfficerTRICARE Management Activity

Overview

• Strategy Review

• Governance

• Current Performance Measures

• Opportunities

• Constraints

2

Strategy Review

• Major drivers– Rising Costs – more beneficiaries, more entitlements and higher utilization– Persistently low satisfaction relative to private sector care

• Foundational step to MHS’ transformation to an ]Accountable Care Organization

• Goal – Implement PCMH model of care at all 470+ primary care practices– Near term – improve PCM continuity, access to care and patient satisfaction– Mid term – manage demand, reduce primary care leakage and ED/primary

care/specialty care utilization, improve HEDIS measures and medically readiness

– Longer-term impacts – Improve beneficiary health status, increase MTF capacity and enrollment and improve MTF resource optimization

3

PCMH Governance

Senior Military MedicalAdvisory Council

Clinical ProponencySteering Committee

Clinical Quality Forum

PCMH Advisory Board

Joint HealthOperations Council

MHS Strategy ManagementWorking Group

Tri-Service PCMH Working Group

Tri-Service PCMH Sub-Working Groups (SWG)

PerformanceMeasures

PMPM AccessTo Care

IM/IT Private SectorCare PCMH

Ad Hoc(Staff Satisfaction,4th Letter MEPRS)

Tri-Service PCMH Performance Measures Sub-Working Group

• Multi-disciplinary, Tri-Service and JTF CAPMED– Gina Julian and Dylan Stearns (TMA/PCMH)

– CDR Chris Hunter (TMA/Behavioral Health)

– Justin Sweetman (TMA/Office of Strategy Management)

– LTC Sharon Pacchiana (TMA/HPA&E)

– Army, Navy, AF and JTF CAPMED Service leads and analysts

• Track, monitor and verify measures– Aggregate into PCMH/Non-PCMH practices

– Develop target and range recommendations

• Recommend new performance measures• Outreach – 600 clinical leaders trained so far (another

500 scheduled for 2d half of FY12)– PCMH, Recognition and PMPM Guidebooks– Practice/real-world experience5

Strategic Imperative

Exec

Sponsor Performance Measure

Development

Status

PreviousPerformanc

eCurrent

Performance Change

FY2011

Target

FY2012

Target

FY2014

Target Strategic Initiatives

Readiness

Improve Individual and Family Medical Readiness

FHPC Medically Ready to Deploy 75% 75% - 81% 82% 85%

Implement Policies, Procedures & Partnerships to Meet Individual Medical Readiness GoalsTBD Measure of Family Readiness (i.e., PHA for families)

Enhance Psychological Health & Resiliency

FHPC PTSD Screening, Referral and Engagement (R/T) 48%/64% 42%/71% -6%/+7% 50%/75% 50%/75% 50%/75%Integrate & Optimize Psychological Health Programs to Increase Resilience, Wellness & Readiness

Implement DoD/VA Joint Strategic Plan for Mental Health to Improve Coordination

FHPC Depression Screening, Referral & Engagement (R/T) 63%/69% 62%/74% -1%/+5% 50%/75% 50%/75% 50%/75%

Population

Health

Engage Patients in Healthy Behaviors

CPSC MHS Cigarette Use Rate (Active Duty 18-24) 26% 21% -5% 19% 18% 16%

Support the National Prevention Strategy to Promote Healthy Behaviors & Total Fitness

CPSCPercent of Overweight/Obese Adults with Documented Weight Issue

17%/54% - 30%/75% 50%/90% 100%/100%

CPSC Percent of Overweight/Obese Adolescents/Children with Documented Weight Issue

11%/33% - 30%/50% 50%/75% 100%/100%

CPSC Exclusive Breastfeeding During Newborn Hospitalization 56% 62% +6% 65% 70% 80%

CPSC HEDIS Index: Preventive Cancer Screens & Well Child Visits (DC/PC)

7/6 8/6 +1/- 10/10 12/14 15/20

Experience of C

are

Deliver Evidence-Based Care

CPSCHEDIS Index: Cardiovascular, Diabetic & Mental Health Care (DC/PC)

23/6 24/5 +1/-1 29/18 36/24 50/35Support the National Partnership for Patients Effort to Improve Care, Transitions and Prevent Harm During Treatment

Wounded Warrior Programs

Disability Evaluation System Redesign

Optimize Pharmacy Practices to Improve Quality and Reduce Cost

Implement Patient Centered Medical Home Model of Care to Increase Satisfaction, Improve Care and Reduce Per Capita Healthcare Costs

Create Alternative Strategy for Purchasing Care to Improve Performance in Achieving the Quadruple Aim.

CPSC Hospital Readmission Rate - - - - - -

CPSC Patient Safety - Wrong Site Surgery - - - - - -

CPSC Antibiotic Received Within 1 Hour Prior to Surgical Incision 94% 95% +1% 98% 98% 98%

Excel in Wounded, Ill and Injured Care

CPSCPercentage of Medical Boards Completed Within 30 Days (DAR & IDES)

53%/67% 41%/53%-12%/-14%

60%/60% TBD TBD

CPSCPercent of Service Members Rating Medical Evaluation Board Experience as Favorable

51% 52% +1% 65% 70% 75%

Optimize Access to Care

JHOC Primary Care 3rd Available Appointment (Routine/Acute) 72%/50% 66%/52% -6%/+2% 91/68% 92%/70% 94%/75%

JHOC Satisfaction with Getting Timely Care Rate 76% 77% +1% 78% 80% 82%

JHOCPotentially Recapturable Primary Care Workload for MTF Enrollment Sites

30% 34% +4% 26% 24% 22%

Promote Patient-Centeredness

JHOC Percent of Visits Where MTF Enrollees See Their PCM 51% 51% - 60% 65% 70%

JHOC Satisfaction with Health Care 59% 59% - 61% 62% 64%

Per

Capita

Cost

Manage Health Care Costs

CFOIC Annual Percent Increase in Per Capita Costs 5.8% 4.3% -1.5% 3.1% - -Implement Alternative Payment Mechanisms to Pay for Value

CFOIC Emergency Room Visits Per 100 Enrollees Per Year 47/100 50/100 +3 35/100 30/100 25/100

Learning & G

rowth

Enable Better Decisions

CPSC EHR UsabilityImplement Modernized iEHR to Improve Outcomes and Enhance Interoperability

Centers of Excellence

Improve Governance to Achieve Better Quadruple Aim Performance in Multi-Service Markets

Foster Innovation CFOIC Effectiveness in Going from Product to Practice (Translational Research)

Develop Our People CFOIC Human Capital Readiness / Build Skills & Currency

CFOIC Primary Care Staff Satisfaction

MHS Strategic Imperatives Scorecard

6Design Phase Approved Funded

Performance Review

• PCMH is accountable for performance• PCMH and Behavioral Health (BH) POM Funding tied to

Performance against set targets• PCMH – one of MHS’ Portfolio of Initiatives (GAO Review)• Key measures

– NCQA Recognition– Enrollees in MTF PCMHs– PCM Continuity– Access to Care– ED Utilization– Recapturable Primary Care (Leakage)– Patient Satisfaction– Staff Satisfaction

NCQA PCMH Recognition

• FY11– 46 Level 3 PCMHs– 1 Level 2 PCMH

• FY12– Army: 50– Navy: 53– Air Force: 25– JTF CapMed: 2

• Support– 7 training events– MHS Guide to Recognition

• Practice Feedback

8

PCMH MTF Enrollment

• POM performance measure• Limited by amount of NCQA recognition funding• Tri-Service PCMH Criteria

– Enrollees in NCQA Recognized PCMHs: 540K– Tri-Service PCMH practices: 1.78M

9

Service Total Prime + Plus# Enrollees in NCQA

or Tri-Svc PCMHs% MTF Enrollment

Army 1,455,375 900,000 62%Navy 724,805 573,228 79%Air Force 1,140,886 808,641 71%JTF CapMed 89,682 33,096 37%Total Direct Care 3,410,748 2,314,965 68%

Source: Services and TOC

PCM Continuity

• Leading indicator of change• The “Provider Accountability”

metric• Improving steadily since Aug

11– AF highest overall– Army most improved: +16%

• NCQA-recognized PCMHs 11% higher than MHS overall in Mar 12– PCMH Average 62%– Above FY12 target of 60%

10

20%

30%

40%

50%

60%

70%

80%

Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

Perc

ent P

CM C

ontin

uity

12 Percent Increase in PCM Continuity Overall

AF Army Navy JTF Goal

20

30

40

50

60

70

80

Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

Aver

age

% P

CM C

ontin

uity

PCMH PCM Continuity 9 percent higher than Overall

NCQA PCMHs MHS OverallSource: TOC

Access to Care – Acute and Routine• Access to Care key to fixing satisfaction and leakage• No Third Next Available data provided

– Inaccurate/sample size too small – resolution pending

• “Days to” better in PCMHs– Acute: 0.5 days vs 0.8 in Mar 12 (36% better in PCMHs than overall)– Routine: 6.3 days vs 6.5 in Mar 12 (5% better in PCMHs than overall)

11Source: TOC

0

1

2

3

4

5

6

7

8

9

Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

Avg

Day

s to

Rou

tine

Avg Days to Routine Appointments

PCMH MHS Overall2 FY12 Goal MHS Std

0

0.2

0.4

0.6

0.8

1

1.2

Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

Avg

Day

s to

Acut

e

Avg “Days to” Acute Appointments

MHS Overall PCMH PCMH Goal MHS Standard

ED Utilization

• ED Utilization is declining as access/PCM continuity improves

• MHS/PCMH averages in the yellow range

• PCMHs have lower ED utilization than direct care overall– Lowest: AF 41.9/Navy 42.3

• Large MTFs with emergency rooms (ERs) have significantly higher utilization than PCMHs in small MTFs with no ERs– Madigan is exception at 36.8

visits/100 enrollees (green)

12Source: HPA&E

30

35

40

45

50

55

60

FY10Q3 FY10Q4 FY11Q1 FY11Q2 FY11Q3 FY11Q4 FY12Q1

ED

Vis

its/

100

En

roll

ees

ED Utilization Direct Care vs. NCQA PCMHs

NCQA PCMHs Direct Care Overall

Potentially Recapturable Primary Care Workload for MTF Enrollment Sites

• Primary Care leakage has improved for three consecutive months– ED utilization declined 12.5% as a

percent of all care– PC by others and UCC utilization

remained steady

• Overall, leakage decreased from 33% in Dec 11 to 27%

• NCQA-recognized PCMH leakage averaged 23% – Achieved FY12 target of 24%– Retrospective data analysis

underway

13Source: HPA&E

0

5

10

15

20

25

30

35

40

Previous Performance Current Performance

% R

ecap

tura

ble

Care

% Total Recapturable Care

MHS Overall NCQA PCMHs FY12 Goal

Patient Satisfaction

• Overall Patient Satisfaction with healthcare is lower than civilian benchmark

• Satisfaction is higher in NCQA-recognized PCMHs– Army has highest satisfaction– Navy has greatest difference between

NCQA recognized PCMHs and non-recognized

• Tri-Service PCMH Advisory Board working with DHCAPE to refine metric down to satisfaction with Primary Care– Best measure is 3QC– Average is 83% for both cohorts

14Source: DHCAPE/TROSS

0102030405060708090

100

MHS Total Army Navy Air Force

% S

atisfi

ed

Percent Satisfaction with Overall Healthcare

Overall PCMHs Civ. Benchmark

0102030405060708090

100

MHS Total Army Navy Air Force

% S

atisfi

ed

Percent Satisfaction with Primary Care

Overall PCMHs

Primary Care Staff Satisfaction

• Dec 11 MHS R&A approved twice yearly survey

• Just completed first FY12 survey (Mar 12)– Lower response rate than in Sep

11 (34 vs 26%)– Satisfaction 2% lower overall at

58% (vs. 59% in Sep)• Service satisfaction rates similar

• Correlation and cohort analysis underway

15Source: DHCAPE/Zogby

3426

05

101520253035404550

Response Rate

% Primary Care Staff Responding

Sep-11 Mar-12

0

10

20

30

40

50

60

70

80

90

100

Army Navy Air Force JTF CapMed Overall

% S

atisfi

ed O

vera

ll

Overall Satisfaction by Service Sep 11 vs. Mar 12

Direct-Care Specific Demonstrations/Studies

• MHS Performance Planning Demonstration• Dr. Jonathon Gruber Study – MIT Economist/chief architect

of the Massachusetts and Obama Administration Healthcare Reform Legislation

– Study PCMH performance impact retro and prospectively

• WRAMC - CMS Healthcare Innovation Challenge Grant Finalist

– Data-driven team care to keep people healthy – assess risk, personalize prevention plan and use risk reduction interventions

– Focus on Outcome Measures - Impact of chronic conditions, increased well-being, reduced ER visits and hospitalizations, improved patient experience, + return on investment

Private Sector Proposed Demonstrations

• Maryland Demo– TRO North to participate in Maryland Demo to test if PCMH model of care

provides higher quality/less costly care and leads to higher patient/staff satisfaction

– Measures: costs, satisfaction, 21 quality measures, admissions, primary care visits, ED visits

– In SACCP coordination

• Other proposed demonstrations with our federal partners in development

Opportunities• PCMH transformation is a process

– We need continued leadership support and emphasis– MHS decisions should align with strategy

• Staff Communication and Outreach• Beneficiary Communication and Outreach

– Increase presence in beneficiaries’ “virtual space”• Focus on performance

– Best Practice proliferation– MTF Cost and Utilization Guidance (PMPM, etc.)– Access to Care Guidance– Focus on High Utilizers/Chronically Ill

• Expanding patient-centered spectrum of care through specialty care optimization and standardization

18

Constraints• Nurse Advice Line implementation delay• 4th Letter MEPRS – embedded specialists• IM/IT and Business Intelligence

– Tri-Service PCMH IM/IT Sub-working Group developed and coordinated High Level Requirements (HLR)

– First PCMH/IMIT Summit held 26-27 Apr 12

• Needs Identified: – Alignment and decision-making between PCMH and IM/IT – $9-13M Secure Messaging unfunded requirements– More reliable, relevant, timely and actionable data– Need to make or buy tools to enhance patient-centered care

• Get rid of what doesn’t work to fund what can– HLR can inform development of iEHR

• Need better cost impact data/tool– Have access to access, continuity and satisfaction but lagging on cost impact data

19

Summary

• PCMH being implemented across not only the MHS but US government, states and private sector

• Foundation of MHS’ move to an accountable care organization

• Most measured, mature and supported MHS Initiative• PCMH concept of care is data-driven

– More/better data and tools needed