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What is the Patient-Centered Medical Home Model ? How Will it Benefit Employers? . Bruce Sherman, MD, FCCP, FACOEM NJBGH – October 12, 2010. Do we get what we pay for?. US Ranks for… Cost: 1 Health: 24 Health System Performance: 37 Financial Fairness: 54.

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what is the patient centered medical home model how will it benefit employers

What is the Patient-Centered Medical Home Model? How Will it Benefit Employers?

Bruce Sherman, MD, FCCP, FACOEM

NJBGH – October 12, 2010

do we get what we pay for
Do we get what we pay for?

US Ranks for…

Cost: 1

Health: 24

Health System Performance: 37

Financial Fairness: 54

what s driving the change recognition we do not get what we pay for
What’s driving the change?Recognition we do not get what we pay for

Health needs

Americans living longer

Average lifespan 77+ years1

Chronic disease more prevalent

> 40% with chronic conditions have > 12

Quality of care

Patients not getting services & not achieving outcomes

More than 50% of patients with diabetes, hypertension, tobacco use, hyperlipidemia, congestive heart failure, asthma, depression and chronic atrial fibrillation were managed inadequately2

45% of adults did not receive recommended care for prevention, acute illness or chronic conditions3

  • US Department of Health and Human Services. Healthy People 2010. Washington DC. US Government Printing Office; November 2000.
  • Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2000.
  • McGlynn EA, et al. N Engl J Med. 2003; 348(26):2635-45.
  • .

- Merck

the value of primary care
The value of primary care
  • Areas with higher density of PCPs have lower hospitalization rates
  • States with more PCPs per capita had higher quality care and lower per capita medical costs
  • Patients with a PCP had 33% lower annual healthcare costs and 19% lower mortality
  • Individuals with PCPs are more likely to receive preventive services, and have better management of chronic conditions

Sepulveda M, et al: Health Affairs 2008;27:151-158

joint principles of the pcmh february 2007
Joint Principles of the PCMH (February 2007)
  • The following principles were written and agreed upon by the four primary care physician organizations – the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association.
    • Principles:
      • Ongoing relationship with personal physician
      • Physician directed medical practice
      • Whole person orientation
      • Coordinated care across the health system
      • Quality and safety
      • Enhanced access to care
      • Payment recognizes the added value
patient centered medical home seven key tenets
Patient-Centered Medical Home: Seven key tenets

Patient has ongoing relationship w/ a personal doctor, or other qualified lead practitioner

A Patient Gateway

NOT a Gatekeeper

The doctor leads a team who collectively provide ongoing care.

Team provides all patient care needs or arranges for care with other qualified professionals.

Information technology links all elements of care (e.g. hospital, specialist, home health agency, nursing home) and the patient’s community (e.g. family).

Creates payment structure recognizing added value provided to patients.

Robust partnership among physicians, patients, and their families; evidence-based medicine and CDS support tools guide decision making; IT supports optimal patient care and enhanced communication.

Expanded hours, open scheduling, better communication.




My patients are those who make appointments to see me

Our patients are those who are registered in our medical home

Patients’ chief complaints or reasons for visit determines care

We systematically assess all our patients’ health needs to plan care

Care is determined by today’s problem and time available today

Care is determined by a proactive plan to meet patient needs without visits

Care varies by scheduled time and memory or skill of the doctor

Care is standardized according to evidence-based guidelines

Patients are responsible for coordinating their own care

A prepared team of professionals coordinates all patients’ care

I know I deliver high quality care because I’m well trained

We measure our quality and make rapid changes to improve it

Acute care is delivered in the next available appointment and walk-ins

Acute care is delivered by open access and non-visit contacts

It’s up to the patient to tell us what happened to them

We track tests & consultations, and follow-up after ED & hospital

Clinic operations center on meeting the doctor’s needs

A multidisciplinary team works at the top of our licenses to serve patients

Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

why should employers care about pcmh
Why should employers care about PCMH?
  • Improved coordination of healthcare
  • Enhanced quality of care
  • Better clinical outcomes
  • Improved patient satisfaction with healthcare
  • And (hopefully) lower health and lost productivity costs
    • Healthier workforce
    • Healthier families in workforce
    • Increased efficiency of care (reduces costs)
    • More valuable health benefit
    • Improved workforce productivity
typical us employer healthcare cost distribution
Typical US employer healthcare cost distribution

PCMH implementation

Current state

  • By improving care quality with a PCMH, primary care costs will increase
  • However, implementation of PCMH has been shown to result in lower hospitalization rates – and lower overall health care costs.
value of a patient centered medical home
Value of a patient-centered medical home
  • Value to patients
    • Better access
    • Safer care
    • Coordinated, longitudinal care
    • Expanded use of evidence-based care
    • Improved compliance with treatment
    • Better outcomes
how connected are you to your primary care physician
How connected are you to your primary care physician?

“Not surprisingly, those patients with the strongest relationships to specific primary care physicians were more likely to receive recommended tests, and be adherent with medicationsand preventive care. In fact, this sense of connection with a single doctor had a greater influence on the kind of preventive care received than the patient’s age, sex, race or ethnicity.”

Patient–Physician Connectedness and Quality

of Primary Care

Atlas, SJ Grant RW, et al. Ann Int Med 2009 :150 :325-335

physician connected patients
Physician-connected patients
  • Study involved 155,590 patients seen in one of 13 primary care practice network sites
  • Patients attributed to physician, practice, or neither based on validated algorithm

Atlas SJ, et al. Ann Intern Med. 2009;150:325-335.

value of a patient centered medical home1
Value of a patient-centered medical home
  • Value to payers
    • Clear practice performance standards
    • Opportunities for incentivizing quality
    • Increased efficiency of care (reduces costs)
  • Value to purchasers
    • Healthier workforce
    • Healthier families in workforce
    • Increased efficiency of care (reduces costs)
    • More valuable health benefit

While other approaches have addressed some PCMH factors, none has addressed them all


P. Grundy, MD. Midwest Business Group on Health, Sept, 2009


PCMH pilots: BCBS North Dakota, MarillacClinic

  • 6% decrease in hospital admissions
  • 24 % decrease emergency room use
  • $500 per member per year savings

Marillac’s Integrated Care Patients (PCMH)

pcpcc payment model
PCPCC payment model

Key physician and practice accountabilities/ value added services and tools

Proactively work to keep patients healthy and manage existing illness or conditions


Coordinate patient care among an organized team of health care professionals


Performance Standards

Utilize systems at the practice level to achieve higher quality of care and better outcomes


Focus on whole person care for their patients

medical home case study whirlpool
Medical home case study: Whirlpool
  • PCMH program started 1/1/10 in Findlay, OH
  • Involves 48 provider practices
  • About 2000 covered lives
  • Comprehensive data collection and analysis
  • Considerable community support
  • Other employers evaluating program participation
medical home potential issues
Medical home – potential issues
  • Lack of consistent definition of “medical home”
  • Lack of best-practice reimbursement approach
  • Cost savings data accumulating – snowball is rolling
  • Patient uptake may be slow based on entitlement philosophy – consideration for incentives
  • Practice reengineering demands may be considerable for small practices, but ample support options available
  • The PCMH model is rapidly gaining attention as an effective means of improving healthcare quality and clinical outcomes
  • Healthcare cost control is emerging as a consistent and potentially substantial outcome
  • Employers can benefit by participating in local/regional PCMH programs
  • To learn more, go to www.pcpcc.net: The Patient-Centered Primary Care Collaborative
patient centered primary care collaborative purchaser guide released july 2008
Patient Centered Primary Care Collaborative“Purchaser Guide” Released July, 2008

Developed by the PCPCC Center for Benefit Redesign and Implementation in partnership with NBCH and the Center’s multi-stakeholder advisory panel.

Guide offers employers and buyers actionable steps as they work with health plans in local markets - over 6000 copies downloaded and/or distributed.

Includes contract language, RFP language and overview of national pilots.

Includes steps employers can take to involve themselves now in local market efforts.

The PCPCC is holding a series of Webinars, sponsored by Pfizer, on the Purchaser Guide.



Patient Centered Primary Care Collaborative“Proof in Practice– A Compilation of Patient Centered Medical Home Pilot and Demonstration Projects” Released October 2009

Developed by the PCPCC Center for Multi-stakeholder Demonstration through a grant from AAFP offering a state-by-state sample of key pilot initiatives.

Offers key contacts, project status, participating practices and market scan of covered lives; physicians.

Inventory of : recognition program used, practice support (technology), project evaluation, and key resources.

Begins to establish framework for program evaluation/ market tracking.



Patient Centered Primary Care Collaborative“A Collaborative Partnership – Resources to Help Consumers Thrive in the Medical Home” Released October 2009

  • Included in the Guide:
  • PCPCC activities and initiatives supporting consumer engagement;
  • Research and examples surrounding consumer engagement in PCMH demonstrations;
  • Tools for consumers and other stakeholders to assist with PCMH education, engagement and partnerships; and
  • A catalogue of resources that provides descriptions of and the means to obtain potential resources for consumers, providers and purchasers seeking to better engage consumers.
Patient Centered Primary Care Collaborative“Aligning Incentives and Systems: VBID and PCMH” Released March 2010
  • Collaborative white paper by PCPCC, Center for Value-Based Insurance Design, and National Business Coalition on Health
  • Discussion of the value of integrating supply and demand-side strategies for employers
  • Case studies of employers, plans and communities implementing these strategies
coming soon from pcpcc
Coming soon from PCPCC…

Employer Metrics for Evaluating the Business Value of Patient-Centered Medical Home Programs

  • Contact info:

Bruce Sherman, MD