Patient-Centered Medical Home: Overview of Commonwealth Fund-Supported Evaluations

1. Patient-Centered Medical Home: Overview of Commonwealth Fund-Supported Evaluations Melinda Abrams, MS The Commonwealth Fund Patient-Centered Primary Care Collaborative Center for Multi-Stakeholder Demonstrations February 23, 2009 www.commonwealthfund.org

2. Commonwealth Fund Commission on a High Performance Health System Established in July 2005 Chairman: James J. Mongan, MD, President and CEO, Partners HealthCare System, Inc. (Boston, MA) Objective: To chart a course for a U.S. health care system that provides significantly expanded access, higher quality, and greater efficiency for all Americans.

3. How Do We Want Health Care To Be Organized and Delivered? 6 Attributions • Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic health record systems. • Patient care is coordinated among multiple providers and transitions across settings are actively managed • Providers (including nurses and other members of the care team) both within and across settings have accountability to one another, review one another’s work, and collaborate to reliably deliver high-quality, high-value care. • Patients have easy access to appropriate care and information, including after hours; there are multiple points of entry to the system; and providers are culturally competent and responsive to patients needs. • There is clear accountability for the total care of the patient • The system is continuously innovating and learning in order to improve the quality, value, and patients’ experiences of health care delivery. Source: Organizing the U.S. Healthcare System for High Performance (August 2008). The Commonwealth Fund Commission on a High Performance Health System.

4. Getting the Care We Want: Policy Recommendations from the Commission • Payment reform • Patient incentives • Regulatory changes • Accreditation • Provider training • Government infrastructure support • Health information technology Source: Organizing the U.S. Healthcare System for High Performance (August 2008). The Commonwealth Fund Commission on a High Performance Health System.

5. Why Are Evaluations of PCMH Demonstrations Important? • Considerable information suggests the patient-centered medical home will result in better quality, improved patient experience and greater efficiency • However, gaps in the evidence exist • Need to rigorously evaluate demonstrations to improve health care and health policy • Need information that is useful to policymakers, purchasers, payers, clinicians and patients • (How many evaluations do we need?)

6. PCMH Evaluations: Key Research Questions • Do physician offices that receive technical assistance and revised payment structure improve their performance on measures of clinical quality, patient experience and efficiency? • Are physician practices able to make the changes necessary to function as patient-centered medical homes? What “worked”? • Is care in PCMHs of higher quality than in non-PCMHs? • Are patients’ experience better in PCMHs than non-PCMHs? • Do PCMHs help slow the rate of health care cost growth? • Do PCMHs help lower health care costs? (Or, lower costs for high-cost groups of patients?) • Do PCMHs help reduce racial/ethnic disparities? • Do physicians/staff in PCMHs report higher job satisfaction than their colleagues practicing in non-PCMH practices? • Does the degree a practice embrace PCMH principles correlate with improvement (clinical, PE, MD satisfaction)?

7. Carlos Jaén, MD, PhD University of Texas Health Science Center Meredith Rosenthal, PhD Harvard School of Public Health Judith Fifield, PhD University of Connecticut NOLA Diane Rittenhouse, MD, MPH University of California, San Francisco Marshal Chin, MD University of Chicago

8. Additional Evaluations Recently Approved (November 2008) MA - CPR Lisa Kern, MD, MPH Weill Cornell Medical Center David Bates, MD, MSc. Brigham and Women’s Hospital Meredith Rosenthal, PhD Harvard School of Public Health

9. Comparison of Demonstrations (1) MA - CPR CO OH

10. Comparison of Demonstrations (1) (continued) NOLA

11. Comparison of Demonstrations (2) MA - CPR CO NOLA OH

12. Comparison of Research Questions (1) MA - CPR CO NOLA OH

13. Comparison of Research Questions (2) MA - CPR CO NOLA OH

14. Comparison of Measures CO MA - CPR OH

15. Challenges/ Concerns • Complex interventions. Will be hard to determine which factor contributed to changes observed • Short time horizons (28-54 months for evaluations) • Small sample sizes • Standardizing measurement across pilots and evaluation projects • High level of enthusiasm among payers and employers . . . Could lead to impatience and premature conclusions • Potentially underfinanced… more funding partners needed

16. What Else We’re Supporting ACP/Urban Institute • Estimate fixed and incremental costs to become and maintain a medical home • Outline payment options NCQA • Test and propose ways to expand PCMH measures to make more patient-centered NASHP • Identify policy options to promote PCMH in Medicaid and SCHIP • Support 8 states Massachusetts General Hospital • Twelve in-depth case studies of high-performing, patient-centered primary care practices

17. What We’re Not Learning:The Short List • Interface between primary, specialty and subspecialty care. How can/should payment promote effective coordination between clinicians? • If all the evaluations show positive results, we will not know which component of the intervention made the difference. Was it the technical assistance? The payment model? • What are the strengths/weaknesses of various curricula to help practices transform? Need comparative analysis. • How do we talk to patients about medical home? Should we evaluate best ways to engage patients and families? How incorporate into a busy practice? • Understanding key components of the PCMH in a practice. For example, what does patient-centered HIT look like? What does team-based care really mean (who, what, etc.)? • How should training of physicians change? What should the curriculum look like to prepare workforce for medical homes?

18. Acknowledgements Elizabeth Hodgman, Program Associate, Patient-Centered Primary Care Initiative Visit the Fund at:www.commonwealthfund.org