After the ACA: Designing health systems with PCMHs, ACOs and PCTs

1. After the ACA: Designing health systems with PCMHs, ACOs and PCTs Nate Kittle, MS4 Robert Graham Center Visiting Scholar October 2012

2. Overview • Background Information • Research Question • Patient Centered Medical Home (PCMH) • Integrated Systems • Accountable Care Organizations – ACOs • Primary Care Trusts (PCTs) • Putting it all together • Conclusions

3. Background Information • Patient Protection and Affordable Care Act • Signed into law March 23, 2010. • Major aim to decrease the number of uninsured Americans • Mandates • Subsidies • Tax Credits • Upheld by SCOTUS on June 28, 2012. http://unlikelyvoter.com/2010/03/25/four-polls-on-the-ppaca-democrats-start-out-behind/

4. PPACA • Implications of PPACA • January 1, 2014 = 14 million U.S. residents newly insured! • By 2021 = Extra 16 million U.S. residents insured • Grand total = approximately 30 MILLION NEWLY INSURED lonelyplanetimages.wordpress.com

5. Who are the 30 Million?

6. Who are the 30 Million?

7. Who are the 30 Million? • Compared with the current insured population these patients will be poorer, older, less likely to have full-time employment, less likely to have a college degree and more likely to speak a language other than English. Only a quarter will have previously had health insurance..

8. The Impact of 30 million • The Massachusetts example • Access and Use of health care improved • More adults reported visits to doctors and fewer adults reporting going without needed health care. • Evidence of strong gains in Preventive care • Challenges • Provider Capacity • “Constraints on provider supply…have ben exacerbated” • Nearly 15% of adults visited the ED for non-emergency conditions • 75% because they needed care after hours • 50% reported not getting an appointment soon enough

9. Research Question • What evidence exists for health system reform that may be able to help curb the possible negative impact of an extra 30 million insured patients and achieve the Triple Aim of reform – Better care for individuals; Better health for the community; and Reduction in the cost of care. • PCMH • Integrated Systems (ACOs) • Primary Care Trusts

10. Patient Centered Medical Home • Brief History • 1967: American Academy of Pediatrics introduced the “medical home” • 2002: The Future of Family Medicine • Every American should have a Personal Medical Home • 2007: Joint principles of the Patient Centered Medical Home • American Academy of Family Physicians • American Academy of Pediatrics • American College of Physicians • American Osteopathic Association

11. PCMH: Joint Principles • Personal Physician • Physician Directed Medical Practice • Whole Person Orientation • Coordinate/Integrated Care • Quality & Safety • Enhanced Access • Payment Reform http://thepcmh.org/

12. PCMH: Realizing the Principles • Robust investment in Health Information Technology • eVisits, eCommunitcation, Personal Health Portals, etc. • Provider payment reform • Focused on patient outcomes and health system efficiencies • Team-based education and training of health professionals • Team of Physician, Case manager, Mental health professional, Nursing, Patient educator, etc. http://www.google.com/imgres?um=1&hl=en&rls=com.microsoft:en-US&biw=1024&bih=603&tbm=isch&tbnid=r3-UkndfnFTR5M:&imgrefurl=http://www.aroragroup.biz/&

13. PCMH: Outcomes • ED Visits • Hospital Admissions • Hospital Length of Stay • Hospital Re-Admissions • Total Costs • Specific Disease Outcomes http://ondemanddentist.com/268/why-you-should-not-go-to-the-er-for-a-toothache/

14. PCMH: Outcomes – ED Visits

15. PCMH: Outcomes – Hospital Admissions

16. PCMH: Outcomes – Length of Stay

17. PCMH: Outcomes – Re-Admissions

18. PCMH: Outcomes – Total Costs

19. PCMH: Outcomes – Specific Diseases

20. PCMH: Criticisms • Variation among programs • Scalability • Infrastructure, care teams, etc. • Large start-up costs • Lack of long-term results

21. PCMH: Criticisms

22. PCMH: Bottom-line • There are obvious benefits to the PCMH model but the extreme variability and large start-up costs cause some states/organizations to hesitate in its implementation. • Is this more than a fad?

23. Integrated Systems • Definitions: • Integration is a set of methods/models on the funding, administrative, organizational, service delivery and clinical levels designed to create connectivity alignment and collaboration between the cure and care sectors. • The goal: enhance quality of care, consumer satisfaction and system efficiency greenologic.co.uk

24. Integrated Systems - Kaiser • Poster Child for Integration • Founded in 1945 • Largest non-profit integrated system in the US • Consist of Kaiser Foundation Health Plans and Permanente Medical Groups • The medical groups are physician owned and function to provide services for health plan members worldchiropracticalliance.org

25. Integrated Systems - Kaiser • Principles • Information Continuity – KP HealthConnect • Care Coordination and Transitions • Valued role of Primary Care • Peer Review and Teamwork • Easy Access to Appropriate Care • Patient-centered • Multiple “entry points” http://67.159.41.164/kp-health-connect.html

26. Integrated Systems - Kaiser • Outcomes • Improving Transitional Care: • Annual cost savings of $4 million from decreased readmissions (2.4% of intervention patients vs 14% usual-care) and ED visits (7%-16% respectively). Satisfaction in the program exceeds 90% of physicians and 95% patients • With the use of multiple “entry points” • Northern California members use of ED declined by 1/3 over the course of 11 years, from rate of 300/1000 adults in 97 to 205/1000 in 08.

27. Integrated Systems - Kaiser • Bottom Line • Rich history of integration that has clearly led to great patient outcomes, patient satisfaction, physician satisfaction and cost reduction. • However, much like PCMH project there needs to be a huge investment in health IT, you need strong leaders to create a culture of excellence.

28. Integrated Systems – ACO • CMS defines ACO: • “an organization of health care providers that agrees to be accountable for the quality, cost and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to the organization.” • Advocates of this system believe that it will strengthen the US health care by improving care, controlling costs, & by holding physicians accountable for results.

29. Integrated Systems - ACO • Challenges to Implementing in the US • Dominance of solo/small-group independent physician practices • Voluntary medical staff structure within most hospitals • Fails to engage physicians in leading the system changes needed to deliver consistently safe, cost-effective and high-quality care • Dominance of FFS reimbursement

30. Integrated Systems - ACO • Medicare’s Physician Group Practice Demonstration • 2000 – Congress asked DHHS to test incentive-based payment methods for physicians which would aim to encourage care coordination and an investment in more efficient service delivery methods. • CMS contracted with 10 large multispecialty groups with diverse organizational structures, including free-standing physician groups, academic faculty practices, integrated delivery systems and a network of small physician practices. • Goal is to generate cost savings by reducing avoidable hospital admissions, readmissions and ED visits while improving quality.

31. Integrated Systems - ACO • PGP Demonstration • Shared Savings: • Received regular Medicare FFS payments • Also eligible for an 80% share of Medicare’s savings in practitioners collectively achieved specified quality and cost targets policymed.com

32. Integrated Systems - ACO • PGP Demonstration Results: • Mixed at best • Quality of Care was improved, but little savings were seen

33. Integrated Systems - ACO • Bottom Line: • There is some reason to be concerned. The results were less then perfect and some analysts believe there may not be enough of an incentive for organizations to restructure in order to qualify for ACO Shared Savings. • There will need to be large investments on health IT, etc. to see the savings necessary to share in the savings. This may be very difficult for your average health care system.

34. Integrated Systems – Other Examples • Advocate • Physician – Hospital partnership • Pay for performance: 10% of allowable billing and based on specialty specific metrics. • Patient outreach, reduced hospital LOS, reduced ED use, etc • In 2010 the partnership distributed $38 million in incentive payments to 3700 physicians. • Group Health • Consumer-governed health plan • Pre-paid group practice that integrates care and coverage. • Salaried physicians – no fee-for-service pressures • Providers, clinics, hospitals and insurance plans under the same organization • Able to make long-term investments in members’ health and manages resources to get best quality and value.

35. Integrated Systems – Other Examples • Geisinger • Large integrated system in Pennsylvania that offers incentives to its physicians to improve patient outcomes an cut costs. (20% total salary) • Specialists: Quality (40%) Innovation (10%) Legacy (10%), Growth (15%) and Financial (25%). • Primary Care: 60% quality measures • Physicians who receive incentives to achieve all diabetes targets have better clinical outcomes for MIs, Strokes, retinopathy, and amputations than patients who receive their care from other physicians.

36. Integrated Systems • Bottom Line: • Mission to manage the full continuum of care and be accountable for the overall costs and quality. Can take several forms: large integrated systems (Kaiser) and Physician-hospital partnerships (Advocate). • Performance measurement to evaluate the quality of care and to prevent potential overuse (FFS) and underuse (Capitation) is a cornerstone of this model. • More fully integrated ACOs provide higher quality, more efficient care than smaller more loosely organized ones. • Kaiser vs Advocate

37. Primary Care Trusts • Brief History • 2000 Launch and • 303 originally established to: • Purchase care for local communities from hospitals and other local providers • Directly provide services such as community care • Work with local agencies to tackle health inequalities/improve public health • 2002 role expansion • Improve health of the community • Secure the provision of high-quality services • Integrate health and social care locally • 2005 – reduced to 152 to match local authorities and strengthen commissioning • 2010 – Role had expanded to more than 60 separate duties 2cuk.co.uk

38. Primary Care Trusts - Outcomes • ED Admissions • Increased by 11.8% from 2004-05 to 2008-09. • 1.35 million extra • Wide variety when Trusts are compared • Some saw increases while others saw decreases • Hypothesize that increase is due to fragmentation of care ukemergency.co.uk

39. Primary Care Trusts - Outcomes • Deficit vs Surplus PCTs • Deficit: In rural areas – 7 times lower population density • Surplus: In more socially deprived areas, staff more stressed • Need to adjust metrics when looking at rural and urban centers to disperse funds in a more equitable manner. • Infant and Perinatal Mortality • 70-80% of PCT variability in infant and perinatal mortality can be explained by combination of deprivation, ethnicity and maternal age • Differences in PCT spending do not reliably explain differences in rates of infant and perinatal mortality seen across the country.

40. Primary Care Trusts - Criticism • Lack of health IT infrastructure to integrate care • Lack of strong leadership • Department of Health priorities limited scope of PCT effectiveness on local level • Extreme variability seen between PCTs alwpctpublichealth.co.uk

41. Primary Care Trusts – Bottom Line • Idea to de-centralize commissioning was good in theory but didn’t necessarily play out over the course of the past decade. • Too many central NHS priorities got in the way of effective PCT response to local needs • Lack of effective leaders trained in commissioning slowed the process and made for an impatient public • 2013 England abolishing PCTs and are headed to new model where GP-led organizations commission services.

42. Taking It a Step Further • The Medical Neighborhood • PCMH + Integrated Care System • Regardless of the organizational structure, an ACO will not succeed without a strong foundation of high-performing primary care • Medical home care coordination and care management activities will enable the ACO to realize cost savings. PCMHs can benefit from ACO infrastructure and support to help PCMHs meet their functional requirements • PCMH is the centerpiece of the medical neighborhood and needs to be nested within a well-functioning medical neighborhood (ACO) that ensures everything that needs to happen does indeed happen. pcpcc.net

43. The Rhode Island Experiment • The Medical Neighborhood + PCTs = The Medical City/County/Township? • Foundation of primary care (PCMH) • Integration across all levels of care (primary and secondary) • Responsive to the local environment by commissioning local services • Spain: 2 decades of reform • Spain ranked 6th among 30 OECD democracies in life expectancy. • Infant mortality in 09 was among the lowest in the world • Reduction in the premature deaths from specific conditions: • Circulatory 322.1 to 159.0/100k population • DM 19.8 to 12.5/100k population.

44. All Models Effect on ED Visits

45. Conclusions • There will be 30 million newly insured citizens by 2021 • Need for primary care is well documented • Continue PCMH programs and report results • Attempt to identify what REALLY works – decrease variability • Care integration can increase quality, but does it decrease costs? • Health IT, Strong physician leadership • Lessons from across the pond • Leadership, only try once, primary care investment works

46. Thank-you! Questions/Comments/Future Actions

47. References (not in Annotated Bibliography) • “Health Insurance Exchanges: Long on options, short on time,” PwC, Oct. 2, (pwc.com/us/en/health-industries/publications/public-private-health-industry-exchange-models.jhtml) • Long, Sharon “What Is the Evidence on Health Reform in Massachusetts and How Might the Lessons from Massachusetts Apply to National Health Reform?” Urban Institute Report. June 2010. • “The Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change” Robert Graham Center Report. November 2007.