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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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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

  • 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


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

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


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

  • 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

  • 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


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

  • 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

  • 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

  • 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

  • Physicians

  • Hospitals

  • Payers


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

  • 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

  • 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

Research, evaluation and commitment will be crucial


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

  • 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

  • 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)


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


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?


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