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The Patient Center Medical Home: Is it the future?. Mark B. Mengel, MD, MPH Vice-Chancellor, Regional Programs June 15th, 2012

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the patient center medical home is it the future

The Patient Center Medical Home: Is it the future?

Mark B. Mengel, MD, MPH

Vice-Chancellor, Regional Programs

June 15th, 2012

(Some of these slides were borrowed from presentations provided by Dr. James McConnell, OHSU, Dr. Joseph Thompson, ACHI, Becky Hall, (Delta-AHEC), Pat Vannatta, (AHEC Central), Dr. Robert Gabbay, Penn State Hershey Diabetes Institute, the Advisory Board, and Dr. James Marsh, (UAMS)

  • Bob Price, Ph.D. and his team at the Central Office
  • AHEC PCMH teams
  • AHEC Clinical Leadership Council
  • Sterling Moore, Jessica Ellis, AHEC business managers, and our back office folks who continuously improve our practice management operations
ahec pcmh goals
  • By the end of June 2012, be able to achieve level II NCQA accreditation.
  • By the end of December 2013, be able to achieve level III NCQA accreditation.*

*Will be accelerated if we participate in the CPCI CMS innovation grant.

the time barrier in p rimary care
The time barrier in primary care
  • 10.6 hours-amount of time it would take the average primary care doctor to provide all evidence-based chronic disease care to an average panel of 2,500 patients, (10 most common chronic diseases)
  • 7.4 hours-preventive care
  • 4.6 hours-acute care
  • 22.6 hours-total, (that does leave 1.4 hours for sleep!)

References: 1. Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3(3):209-214.

2. Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93(4):635–641.

3. Stange KC, Zyzanski SJ, Jaén CR, et al. Illuminating the ‘black box’. A description of 4454 patient visits to 138 family physicians. J FamPract. 1998;46(5):377–389.


Tomorrow: Keeping Patients Healthy

Multi-Disciplinary Team

transformed learnings
  • PCMH is a transformation of a practice, (3 to 5 years), not a small incremental change
  • Requires capability for organizational learning and development, (Leadership is key!)
  • Change in relationships, (with patients, staff, other providers)
  • Supportive health care neighborhood
  • Reimbursement model changes-care management fees and shared savings
Strengthening Primary Care and Care Coordination in Medicare: Distribution of 10-Year Impact on Spending

Dollars in billions


Source: C. Schoen et al., Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending, The Commonwealth Fund, December 2008.

ahec pcmh costs
  • Decreased productivity
  • Additional Team members not currently present
  • Purchase and on-going operational costs of EMR’s and other IT tools
  • Time for staff to meet to design and implement new workflows
  • Education and marketing to patients
ahec pcmh it costs
  • Initial purchase and license fees; lost productivity; training and consultants; server virtualization: $3,487,6000 (can offset with meaningful use money-AHEC estimate: $3,264,750)
  • Annual maintenance and IT personal costs: $703,316
additional team members
Additional Team Members
  • Health Psychologist (1)
  • PCMH Nurse Coordinator (1)
  • Medical Assistants or Care Coordinators (2 or 3)
  • Outreach Workers (2 or 3)
  • Central Office support: IT Project Manager (1), RN Case Manager (3), Nutritionist (1)
  • (AHEC’s have NP’s, except AHEC-NE, and Pharmacists, already.)
  • TOTAL AHEC Annual Implementation Costs: $3,164,438. (For the Equivalent of 35.96 FTE Providers in our FMC’s.)
total pcmh annual costs
Total PCMH annual costs
  • $703,316 + $3,164,438=$3,867,754.
  • Per AHEC: $644,625
  • Per FTE Provider: $107,437
estimated pcmh incremental costs
Estimated PCMH incremental costs
  • $100,000-$115,000 per primary care clinician,
  • $78,000 per health coach; 56 percent load for coaching tools (data collection, telephones, IT systems, etc.);
  • 33 percent FTE data manager at $65,000 per data manager;
  • and $5,000-$20,000 for health IT and Web site technical support annual maintenance.

*Deloitte Center for Health Solutions. The Medical Home: Disruptive Innovation for a new Primary Care Model. 2008.

cms innovation center s comprehensive primary care initiative
CMS Innovation Center’s Comprehensive Primary Care Initiative
  • 7 Markets selected, AR (state-wide) included
  • Insurance involved: Medicare, Medicaid, QualChoice, and Blue Cross and Blue Shield
  • 4 year pilot project of 75 adult primary care practices in Arkansas
    • EMR
    • 150 eligible Medicare beneficiaries
    • 60% of revenues generated by payers participating
    • Level 1 MU perfered; NCQA PCMH level 1, 2, or 3 preferred or document performance of comprehensive primary care functions
comprehensive primary care functions
Comprehensive Primary Care Functions
  • Risk-stratified case management
  • Access and continuity
  • Planned care for chronic conditions and prevention care
  • Patient and care giver engagement
  • Coordination of care across the medical neighborhood
cpci case management fees
CPCI Case Management Fees
  • Medicare: Average $20 per patient per month first two year, risk adjusted. Decrease to $15 on average in year 3 and 4.
  • Medicaid: preliminary estimate $7 per patient per month, not risk adjusted, includes kids.
  • QualChoice: $3 per patient per month, not risk adjusted.
  • Blue Cross and Blue Shield: $5 per patient per month, not risk adjusted.
  • SHARED SAVINGS: Only in year 3 and 4, no rules, yet.
  • CONCLUSION: Only Medicare will cover PCMH capacity costs.
are others on the pcmh train
Are others on the PCMH train?
  • Recent MGMA survey: 36% of FM practices moving toward PCMH
  • Recent MGMA survey: 20% of practices, including multispec groups, have achieved PCMH NCQA accrediation
  • Ark BCBS pilots (7)
  • UAMS Center for Primary Care: PCMH’s in FM, Gen IM, and Geriatrics (along with Smart Care).

It’s already starting

NEJM | March 30, 2011 |




closing thought
Closing thought

“Making systems work in health care-shifting from corralling cowboys to producing pit crews-is the great task of your and my generation of clinician and scientists.”

AtulGawande, M.D.

Harvard Medical School Commencement

May 26, 2011