The Evolution of Medical Homes The Evolution of Medical Homes and the Role of Health Centersand the Role of Health Centers

Presentation to National Congress Presentation to National Congress on Health Reformon Health Reform

September 23, 2008September 23, 2008

Dan Hawkins

National Association of

Community Health Centers

The “Medical Home” DefinedThe “Medical Home” DefinedACP, AAFP, AAP, AOAACP, AAFP, AAP, AOA

• Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, 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 taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

• Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

The “Medical Home” Defined (cont’d)The “Medical Home” Defined (cont’d)• Quality and safety are hallmarks of the medical home:

– Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes.

– Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met.

– Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication.

• Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.

• Payment appropriately recognizes the added value provided to patients who have a Patient-Centered Medical Home.

– It should reflect the value of physician and non-physician staff care management work that falls outside of the face-to-face visit.

– It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management.

– It should allow for additional payments for achieving measurable and continuous quality improvements.

Medical Home ConceptMedical Home Concept

• Organize the delivery of care for all patients according to the Chronic Care Model

• Use evidence-based medicine and clinical decision support tools

• Coordinate care in partnership with patients and families• Provide enhanced and convenient access to care• Identify and measure key quality indicators• Use health information technology to promote quality,

safety & security of information• Participate in programs that provide feedback on

performance & accept accountability for process improvement and outcomes

Wagner Model for Effective Prevention Wagner Model for Effective Prevention and Chronic Illness Careand Chronic Illness Care

56 Million Americans Lack a 56 Million Americans Lack a Medical HomeMedical Home

• Nearly 1 in 5 (19.3%) men, women, and children (56 million people) reported lacking a Usual Source of Care– 52% of all uninsured people under 65 years of age

have no USC– Nearly a quarter (24%) of all poor or near-poor are

without a USC– Of those without a USC, 32% are uninsured and 21%

are low income– 32% of all Hispanic or Latino Americans have no USC – 23% of all Black,non-Hispanic people have no USC

Source: 2004 Medical Expenditure Panel Survey

America’s Community Health CentersAmerica’s Community Health Centers

• Medical homes for 18 million+ at risk patients

• Mission: Improve the health of medically underserved communities

• Program requirements:

– Location in medically underserved area

– Comprehensive, tailored health care services

– Open to all regardless of ability to pay

– Community Governance

– Not for profit

Health Centers as “Health Care Homes”Health Centers as “Health Care Homes”

• Personal physicians and other providers• Patient-centered• Care for patients throughout the lifecycle • Deliver care in a team-based setting• Coordinating and integrating care• Services beyond traditional primary care• Enhanced access to care• Formalized Quality Improvement program

Health Center Disparities CollaborativesHealth Center Disparities Collaboratives

• Transforming CHC practice from episodic to continuous care

• Based on Wagner Care Model– Clinical Information Systems– Self Management Support– Evidence based practice– Delivery System Redesign

• Nearly all Health Centers trained and involved• Common reporting on measures• Currently over 500,000 patients in registries

Beyond the Medical HomeBeyond the Medical Home

• Addressing the deeper roots of disparities– Economic Security

– Health Professions Educational and Career Opportunities

– Addressing Discriminatory Practice and Building Trust

• Linkages to educational and economic community institutions

• Assistance in accessing economic benefits

• Building a diverse healthcare workforce and delivering care in a team-based setting

• Provision of care not normally seen in primary care settings (eg, alternative medicine)

40%

71% 66%

92%

35% 34%

17%16% 13%

36%

0%

20%

40%

60%

80%

100%

Uninsured Medicaid At or below100% ofPoverty

Under 200% ofPoverty

Minority

Health Centers U.S.

Health Center Patients are Poorer, More Health Center Patients are Poorer, More Uninsured and More Minority than US PopUninsured and More Minority than US Pop

Sources: Health Center: 2006 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. US: Kaiser Family Foundation, State Health Facts Online, www.statehealthfacts.org. See the following tables: “Health Insurance Coverage of the Total Population,” “Distribution of Total Population by Federal Poverty Level,” and “Population Distribution by Race/Ethnicity.” US data are from 2006.

4.5%

6.3%

7.6%

2.8%

5.4%

1.4%

2.5%

6.7%

1.4%2.0%

0%

2%

4%

6%

8%

MentalDisorders

Heart Disease Diabetes Asthma Hypertension

Office-Based Physician Patients Health Center Patients

Health Center Patients are Generally More Health Center Patients are Generally More Likely to Have a Chronic Illness than Patients Likely to Have a Chronic Illness than Patients

of Office-Based Physiciansof Office-Based Physicians

Source: Rosenbaum et al. “Health Centers as Safety Net Providers: An Overview and Assessment of Medicaid’s Role.” 2003. Kaiser Commission on Medicaid and the Uninsured. Center for Health Services Research and Policy analysis of 2004 UDS. Office-based physician data based on 2002 National Ambulatory Medical Care Survey.

Nearly All Health Center Patients Report Nearly All Health Center Patients Report that They Have a Usual Source of Carethat They Have a Usual Source of Care

Source: AHRQ, “Focus on Federally Supported Health Centers,” 2002. National Healthcare Disparities Report. http://www.qualitytools.ahrq.gov/disparitiesReport/browse/browse.aspx?id=4981

98% 98% 98% 97% 99%

0%

25%

50%

75%

100%

Non-hispanicwhite

AfricanAmerican

Hispanic Uninsured Medicaid

Health Center Uninsured Patients Receive Health Center Uninsured Patients Receive More Care than the Uninsured NationallyMore Care than the Uninsured Nationally

97.5%

56.0%64.9%

33.3%

0%

20%

40%

60%

80%

100%

Has a Usual Source of Care 4 or More Doctor Visits/Year

Health Center Uninsured U.S. Uninsured

Source: Leiyu Shi, “The Role Of Health Centers In Improving Health Care Access, Quality, And Outcome For The Nation's Uninsured.” Testimony At Energy and Commerce Committee, Subcommittee on Oversight and Investigations Congressional Hearing “A Review Of Community Health Centers: Issues And Opportunities.” Washington, DC. May 25, 2005. Based on Community Health Center User Survey, 2002, Preliminary Tables August 2004; and National Health Interview Survey, 2002.

Health Center Uninsured Patients are Twice Health Center Uninsured Patients are Twice as Likely To Get the Care They Need Than as Likely To Get the Care They Need Than

Other UninsuredOther Uninsured

25%

12%16%

55%

30%24%

0%

20%

40%

60%

Delayed Care Due toCost

Went Without NeededCare

Could Not Fill Rx

Health Center Uninsured Other Uninsured

Source: Politzer, R., et al. “Inequality in America: The Contribution of Health Centers in Reducing and Eliminating Disparities in Access to Care.” 2001. Medical Care Research and Review 58(2):234-248.

Health Center Diabetes Patients Receive More Health Center Diabetes Patients Receive More Care than Other Low Income DiabeticsCare than Other Low Income Diabetics

63%

78%

26%

62%

52%

23%

60%67%

0%

20%

40%

60%

80%

Eye Exam Foot Exam Flu Shot** Pneumovax**

Health Center Patients Low Income Nationally

*

*p<0.05 **Age > 65 years Source: Leiyu Shi, “The Role Of Health Centers In Improving Health Care Access, Quality, And Outcome For The Nation's Uninsured.” Testimony At Energy and Commerce Committee, Subcommittee on Oversight and Investigations Congressional Hearing “A Review Of Community Health Centers: Issues And Opportunities.” Washington, DC. May 25, 2005. Based on Community Health Center User Survey, 2002; and National Health Interview Survey, 2002. Created by: BA Bartman, CQSB/DCQ/BPHC/HRSA, July 2004.

Health Center Health Center UninsuredUninsured Patients Receive Patients Receive More Health Promotion Counseling than the More Health Promotion Counseling than the

Uninsured NationallyUninsured Nationally

52%58%

65% 64% 67%73%

62%54%

49%45%42%38%

0%

20%

40%

60%

80%

100%

STDs Drugs Diet Exercise Alcohol Smoking

Health Center Uninsured U.S. Uninsured

Source: Leiyu Shi, “The Role Of Health Centers In Improving Health Care Access, Quality, And Outcome For The Nation's Uninsured.” Testimony At Energy and Commerce Committee, Subcommittee on Oversight and Investigations Congressional Hearing “A Review Of Community Health Centers: Issues And Opportunities.” Washington, DC. May 25, 2005. Based on Community Health Center User Survey, 2002; and National Health Interview Survey, 2002. Created by: BA Bartman, CQSB/DCQ/BPHC/HRSA, July 2004.

49%58% 61% 65%

71%82%

54%

43%48%49%

32%37%

0%

20%

40%

60%

80%

100%

STDs Drugs Diet Exercise Alcohol Smoking

Health Center Medicaid U.S. Medicaid

Health Center Health Center MedicaidMedicaid Patients Receive Patients Receive More Health Promotion Counseling than More Health Promotion Counseling than

Medicaid Patients NationallyMedicaid Patients Nationally

Source: Leiyu Shi, “The Role Of Health Centers In Improving Health Care Access, Quality, And Outcome For The Nation's Uninsured.” Testimony At Energy and Commerce Committee, Subcommittee on Oversight and Investigations Congressional Hearing “A Review Of Community Health Centers: Issues And Opportunities.” Washington, DC. May 25, 2005. Based on Community Health Center User Survey, 2002; and National Health Interview Survey, 2002. Created by: BA Bartman, CQSB/DCQ/BPHC/HRSA, July 2004.

96%

78%88% 86%

71%75%78%79%

0%

20%

40%

60%

80%

100%

Hispanic African American Medicaid Uninsured

Health Centers Nationally Healthy People 2010 Target (70%)

Health Centers Reduce Disparities in Health Centers Reduce Disparities in Access to MammogramsAccess to Mammograms

% of Women 40+ and <200% FPL Receiving Mammograms

Source: Leiyu Shi, “The Role Of Health Centers In Improving Health Care Access, Quality, And Outcome For The Nation's Uninsured.” Testimony At Energy and Commerce Committee, Subcommittee on Oversight and Investigations Congressional Hearing “A Review Of Community Health Centers: Issues And Opportunities.” Washington, DC. May 25, 2005. Based on Community Health Center User Survey, 2002; and National Health Interview Survey, 2002.

Health Centers Also Reduce Disparities Health Centers Also Reduce Disparities in Access to Pap Testsin Access to Pap Tests

94%86%95% 92%

77%

90%89%91%

0%

20%

40%

60%

80%

100%

Hispanic African American Medicaid Uninsured

Health Centers Nationally

% of Women 18+ and <200% FPL Receiving Pap Smears in Last 3 Years

Source: Leiyu Shi, “The Role Of Health Centers In Improving Health Care Access, Quality, And Outcome For The Nation's Uninsured.” Testimony At Energy and Commerce Committee, Subcommittee on Oversight and Investigations Congressional Hearing “A Review Of Community Health Centers: Issues And Opportunities.” Washington, DC. May 25, 2005. Based on Community Health Center User Survey, 2002; and National Health Interview Survey, 2002.

Health People 2010 Target (70%)

Health Center Patients Have Lower Rates of Low Birth Weight than Their U.S. Counterparts

Source: Shi, L., et al. “America’s health centers: Reducing racial and ethnic disparities in prenatal care and birth outcomes.” 2004. Health Services Research, 39(6), Part I, 1881-1901.

7.7%

13.0%

14.9%

6.0%

9.1%

6.8%6.5%7.5% 7.5%

8.2%7.4%

5.6%

10.7%

6.6%7.5%

0%

5%

10%

15%

Total Asian Black Hispanic White

U.S. U.S. Low Income Health Center

• Are between 11% and 22% less likely to be hospitalized for avoidable conditions

• Are 19% less likely to use the ER for avoidable conditions

• Have lower hospital admission rates, lower lengths of hospital stays, less costly admissions, and lower outpatient and other care costs

Compared to Medicaid Patients Treated Compared to Medicaid Patients Treated Elsewhere, Health Center Medicaid PatientsElsewhere, Health Center Medicaid Patients……

Sources: Falik et al. “Comparative Effectiveness of Health Centers as Regular Source of Care.” 2006. Journal of Ambulatory Care Management29(1):24-35. Falik et al. “Ambulatory Care Sensitive Hospitalizations and Emergency Visits: Experiences of Medicaid Patients Using Federally Qualified Health Centers.” 2001. Medical Care 39(6):551-56.

Saving 30-33% in total costs per Medicaid beneficiary

Health Centers Provide Health Centers Provide One-FifthOne-Fifth of All of All Ambulatory Care for Uninsured…Ambulatory Care for Uninsured…

Proportion of Visits by Uninsured, 2004 (N = 70 Million)

Hospital OPDs (7%)

Private Physicians

(51%)

Health Centers (22%)

Hospital ER Units (20%)

National Association of Community Health Centers - 2007

……But Millions of Americans Have No But Millions of Americans Have No Regular Source of CareRegular Source of Care

56 Million People Have No Regular Source of Care (not even a Health Center)• Half are Uninsured• 40 percent are Members of Minority Groups• In 21 states, they number More Than 1 Million

46 Million People are Uninsured• Three-fifths are in Low-Income Families• One in 3 Latinos is Uninsured

The The Access for All AmericaAccess for All America Plan Plan• Grow health centers program to serve 30 million people

by 2015 by –

– Developing new CHC sites and expanding existing sites

– Funding every health center for oral and mental health, and for pharmacy services

– Increasing workforce training programs (especially NHSC) to build primary care workforce for all

– Increasing support for new facilities, equipment, HIT, and quality/performance improvement

– Maintaining Medicaid and SCHIP coverage, and expanding it wherever possible

• Ultimately, grow health centers to serve 51 million people by 2022

Health Centers Save the System BillionsHealth Centers Save the System Billions• Medical expenses for Community Health Center

patients are 41% lower compared to patients seen elsewhere – $1,810 per person annually.

• If Congress invests in Community Health Centers today, an estimated 30 million Americans could have access to their high-quality by the year 2015, resulting in health care savings of up to $40.4 billion annually.

• Nationwide, Community Health Centers produced $12.6 billion in economic benefits and brought 143,000 jobs to their low-income communities.

• If Congress invests in Community Health Centers today, the economic benefits would rise to almost $41 billion, generating over 460,000 full-time jobs in 2015.

Source: NACHC, Robert Graham Center, and Capital Link, Access Granted: The Primary Care Payoff, August 2007, www.nachc.com/research.