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Patient-Centered Medical Home: From Concept to Reality. Consumer Purchaser Disclosure Project October 17, 2007 Lisa Latts MD, MSPH VP, Programs in Clinical Excellence. ME. NH. WI. MA. CT. OH. NV. IN. IL. CO. CA. VA. MO. KY. GA. TX. BC or BCBS licensed plans.

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Patient centered medical home from concept to reality l.jpg

Patient-Centered Medical Home: From Concept to Reality

Consumer Purchaser Disclosure Project

October 17, 2007

Lisa Latts MD, MSPH

VP, Programs in Clinical Excellence


Wellpoint inc l.jpg

ME

NH

WI

MA

CT

OH

NV

IN

IL

CO

CA

VA

MO

KY

GA

TX

BC or BCBS licensed plans

UniCare >100K members

WellPoint, Inc

More than 34 million Members Across the Country

NY


Patient centered medical home l.jpg

Definition of an “Patient-Centered Medical Home” (PCMH): a primary care practice that provides patients with accessible, continuous and coordinated care through a patient-centered, physician-guided, cost-efficient and longitudinal approach to care

What is a Medical Home:*

Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care

Physician-directed medical practice in which a team of individuals collectively take responsibility for ongoing care of patients

Whole-person orientation of care for all stages of life

Care is coordinated and/or integrated across all elements of the health care system

Quality and safety are hallmarks of the medical home

Patients have enhanced access to care through systems such as open scheduling, expanded hours and new options for communication

Payment appropriately recognizes the added value to patients who have a medical home

Medical Home is NOT:

Reemergence of capitation

Just another way to increase primary care reimbursement

Panacea for rising heath care costs

Net increase of dollars into the health care system

Patient-Centered Medical Home

* Adopted by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP),

American College of Physicians (ACP) and the American Osteopathic Association (AOA)


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Why the Medical Home

  • Primary care is important to the delivery system – current crisis in primary care recruitment and retention

    • Medical home may be the (a) answer to increased quality, reimbursement and provider/patient satisfaction

  • Aging population & increased prevalence of chronic diseases

  • Current system emphasizes episodic treatment for acute care and more care, not better care; Capitation led to less care

  • Rising healthcare costs and gaps/variations in quality and safety

  • Need for better coordination of care among providers; care coordinated by a personal physician associated with better outcomes, especially in many chronic diseases

  • Disease management as currently exists yielding mixed results; DM activities most successful when integrated into a physician practice

  • Collaboration with national and local primary care providers to explore innovations and piloting PCMH models

  • Goals to improve safety, quality, affordability, and experience of care


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Collaborating for Quality and Affordability

  • Primary Care

  • ACP

  • AAFP

  • AOA

  • AAP

Purchasers

Patient-Centered

Medical Home

Patient Advocacy Groups

  • Health Insurers

© 2007 Blue Cross Blue Shield Association. All Rights Reserved.


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Implement in states across the country

Recruit variety of practice shapes and sizes

Large IPAs/ multi-specialty groups

Smaller PCP group practices

Solo and Duo Practice groups

NQCQ Practice Designation - PPC

Timing: Q1/Q2 2008

Coordinate pilot sites with other payers, especially CMS

Critical mass of patients necessary for PCMH success

Coordinate with other programs

Pay for Performance

Disease Management

Transparency Programs

Decision-support

Care Coordination

Health Information Technology

Clinical Process and Outcome Measures

Resource Use

Cost of Care

Satisfaction

Pilot Program Model

Coordination

Implementation

Evaluation

  • Comprehensive evaluation

  • Discussions with Commonwealth Fund, RAND


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Patient-Centered Medical Home

Demonstrations- BCBSA

2007-2008 Pilot Planning

WA

ME

MT

ND

MT

VT

NH

MN

OR

MA

WI

NY

SD

ID

ID

MI

RI

WY

NJ

PA

CT

IA

NE

OH

MD

NV

DE

IN

NV

IL

WV

DC

UT

CA

CO

VA

MO

KS

KY

NC

TN

NM

OK

SC

AR

AZ

AL

GA

MS

LA

TX

AK

FL

HI

PR

PR

= States where PCMH demonstrations are in planning for 2008

Participation as of 10/15/07


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Personal Medical Home

Reimbursement and incentive structure aligned to support

practice transformation, clinical process/outcomes, cost of care and satisfaction

Payment Methodology

Prospective Payment

Pay For Quality

FFS

For services currently recognized through Medicare RBRVS system; potential for additional services

  • NCQA’s

  • PPC Recognition:

  • Care Coordination

  • Process Redesign

  • HIT

  • Evaluate Levels of Achievement

Clinical

Process and Outcomes

Resource Use/

Cost of Care

Satisfaction

Pre-Assessment of Practice Readiness

Support from ACP, AAFP and AAP


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Practice Recruitment

Current WellPoint interest in ME, NH, WI, VA, CO, CA

Coordinate with local ACP, AAFP chapters to recruit

Urban/suburban/rural

Large/medium/small/single

What is critical payer mass for practice

PCMH Designation

NCQA PPC Program – time to get practices designated

Who pays?

Differences by level of designation attained

Technical Support

“Reward” for increasing levels

Purchaser participation

Employee incentives to use Medical Home practices?

Care Coordination Payment

All patients or just chronic disease? Which disease(s)?

How much? How often?

Opt in or opt out model for patients

Timing of Program: Start, interim evaluation, final evaluation

At least 18 month for adequate trial of effects

What to do in the interim

Evaluation

Where, What, Who and How

Definition of Success?

Key components of success vs. elements that provide no incremental value

Transparency

What if…..

PCMH Project Questions


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