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The path to health care system transformation: Patient Centered Medical Homes and Accountable Care Organizations. Florida Public Health Institute/Community Health NETwork Carl Patten, JD, MPH Director, Florida Blue Center for Health Policy August 27, 2013. Agenda and Overview.

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Florida public health institute community health network carl patten jd mph

The path to health care system transformation: Patient Centered Medical Homes and Accountable Care Organizations

Florida Public Health Institute/Community Health NETwork

Carl Patten, JD, MPH

Director, Florida Blue Center for Health Policy

August 27, 2013


Agenda and overview

Agenda and Overview

  • Key drivers of and obstacles to changes

  • Seizing the future: the role of patient-centered medical homes and accountable care organizations

  • Navigating the chasm

  • Key takeaways

  • Questions


Key drivers of and obstacles to change

Key drivers of and obstacles to change


The need for change has long been clear but the path is not

The need for change has long been clear, but the path is not.

  • Drivers of change

  • Access

  • Quality

  • Cost

  • Obstacles to change

  • Entangled and complex challenges

  • Requires comprehensive solutions

  • Political sensitivity


Seizing the future

Seizing the future

The role of patient-centered medical homes and accountable care organizations


Pcmhs is supported by significant history and broad stakeholder alignment

PCMHs is supported by significant history and broad stakeholder alignment

  • History

  • Medical Home concept established in 1967

  • Chronic care model established in 1996

  • Joint PCMH Principles established in 2007 (ACA)

  • Stakeholder Acceptance

  • Joint Principles of the Patient Centered Medical Home endorsed by AAFP, AAP, ACP and American Osteopathic Association

  • Patient-Centered Primary Care Collaborative: employers, physician groups, labor unions, health plans, consumer groups and other stakeholders

  • NCQA PCMH 2011 Standards


Although the pcmh model is well established it is not a panacea

Although the PCMH model is well-established, it is not a panacea

  • Requires funding for robust implementation and impact

  • Significant workflow redesign and organizational culture changes required

  • Requires high level of cooperation within and among practices and organizations


Acos have less history than pcmhs but the model is connected to other concepts

ACOs have less history than PCMHs, but the model is connected to other concepts

  • Legal and financial infrastructure to create appropriate incentives

    • Flexibility

    • “Medical neighborhood”

  • Rooted in concepts such as HMOs, pay-for-performance and other approaches to improve the cost-effectiveness of care

  • Formalized by Dr. Eliott Fisher in 2006


Although there are overlapping concepts between pcmhs and acos they have distinct roles

Although there are overlapping concepts between PCMHs and ACOs, they have distinct roles


Relationship between pcmhs and acos

RELATIONSHIP BETWEEN PCMHs AND ACOs

  • PCMHs ARE THE “WHAT”, AND ACOs ARE THE “HOW” THAT DELIVERS THE “WHAT”.


Providers will likely take on more risk moving forward

Providers will likely take on more risk moving forward

  • Medical trend continues to outpace CPI. Driven in part by:

    • Fragmented fee-for-service

    • Provider consolidation

The Accountable Care Glide Path


The transition of risk allocation must be purposeful yet strategic

The transition of risk allocation must be purposeful, yet strategic

  • How does risk allocation to ACOs impact the quality and cost of care for different populations?

  • Specialized skill

  • The capacity to manage risk will likely differ among organizations

  • Consumers must be protected; however, organizations must not be unnecessarily burdened


There are other unanswered questions

There are other unanswered questions

  • Payment and risk

  • How to overcome the entrenchment of fee-for-service model?

  • Is the ability to assess the risk of populations assigned to ACOs adequate?

  • What is the best way assign patients to ACOs?

  • How will the financial health of ACOs be monitored?

  • How are patients and families adequately engaged?

  • Operational

  • Can the cultural transition to population health be made?

  • How will HIT and administrative infrastructure requirements be addressed?


The neighbors are restless

The neighbors are restless

  • Physicians

  • Hospitals

  • Payers


However public sector efforts are robust regarding pcmhs and acos

However, public sector efforts are robust regarding PCMHs and ACOs

  • PCMHs

  • Federal PCMH Collaborative

  • Policies and programs promoting PCMHs have been adopted by 43 states

  • Community Care of North Carolina

    • Links Medicaid and CHIP enrollees to community-based primary care

    • $1 billion savings over 4 years

  • ACOs

  • Medicare Shared-Savings Program

  • Pioneer ACO Program

  • Advance Payment ACO Program


Private sector efforts are becoming more prevalent

Private sector efforts are becoming more prevalent

  • As of August of 2012, 80 organizations identified having private pay only or public and private pay ACO contracts

  • Blue Shield of California and CalPERS ACO pilot

    • 40,000 members

    • $15 million in savings

  • BCBS of Massachusetts Alternative Quality Contract

  • Brookings-Dartmouth Partnership


Florida blue is demonstrating leadership in the effort to implement pcmhs and acos

Florida Blue is demonstrating leadership in the effort to implement PCMHs and ACOs

  • Approximately 30% of medical spend is through value based models

  • One of the largest PCMH programs in the country with over 2,200 PCPs and 240 groups

  • Eight ACO agreements with more in the pipeline

  • Physicians in PCMH program have performed the same or better compared to non-participating peers in all of the 29 metrics

  • Emergency room visits have dropped by 12%

  • Overall cost reduction of 4% during the first year


Navigating the chasm

Navigating the chasm

Research, evaluation and commitment will be crucial


Florida public health institute community health network carl patten jd mph

Research conducted to-date indicates PCMHs and ACOs are promising and provide direction for improvement

  • Signs of success

  • PCMH model has an established history and is built on firm evidence

  • Several PCMH programs have produced improved quality, cost savings and better coordination among high risk/high need patients

  • ACOs have been successful in engaging physicians and moving the needle in forming agreements linking payment to quality measures and efficiency

  • Opportunities for improvement identified by the research

  • Patient engagement

  • Reducing utilization among low-risk patients

  • Patient and provider education

  • Useful data sharing between payers and providers


There is much more to learn

There is much more to learn

  • Examples of systemic issues

  • Coordination of public and private multi-payer programs

  • Impact of models on vulnerable populations

  • Example of organizational issues

  • Desired leadership characteristics needed for organizational adaptation

  • Feasible financing models

  • Allocation of resources (human, financial, technological)

  • Stakeholder dynamics, including community organizations

  • Standardization of performance measures of ACOs and PCMHs


The public and private sectors must work together to navigate the unknown

The public and private sectors must work together to navigate the unknown

  • Encourage broad participation and a broad variety of structures

  • Information sharing

  • Encourage robust participation and research within the private sector through appropriate incentives

  • Coordination of implementation and requirements (performance measures and payment incentives)


Florida public health institute community health network carl patten jd mph

Evaluation of ACOs must advance beyond formation of the neighborhood to the effectiveness of the neighborhood

  • Most evaluation efforts have focused on the ability to form ACOs

  • Relationship between risk presented by various payment models and ability to improve quality and efficiency of care

  • Impact on vulnerable populations and providers that deliver care to them


Key takeaways

Key Takeaways


Takeaways

Takeaways

  • PCMHs are rooted in primary care and backed by history and strong evidence

  • ACOs serve as catalysts for the proliferation of PCMH principles throughout the health care system

  • These models have gained significant traction

  • We are at the precipice of a journey of transformation that will require continuous learning, broad participation and research and evaluation

  • Research and evaluation must be coordinated and build upon efforts to identify core metrics for useful comparisons to inform implementation efforts


Questions

Questions?


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