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