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Maine Multi-Payer Pilot Patient Centered Medical Home Model. A Collaborative Effort of the Maine Quality Forum, Quality Counts, & the Maine Health Management Coalition. Lisa M. Letourneau MD, MPH. November 2008. Objectives.

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Maine Multi-Payer Pilot

Patient Centered Medical Home Model

A Collaborative Effort of

the Maine Quality Forum, Quality Counts, & the Maine Health Management Coalition

Lisa M. Letourneau MD, MPH

November 2008

  • Review history, principles of Patient Centered Medical Home model
  • Describe development, goals for Maine Multi-payor Pilot of PCMH model
  • Outline key steps for successful PCMH pilot implementation in Maine
the facts
The Facts

More (and more) U.S. health care spending…

Why Not the Best? Results from the National Scorecard on U.S. Health System Performance 2008, Commonwealth Fund

the facts6
The Facts

More primary care services are associated with better outcomes

*Rank based on patient satisfaction, expenditures per person, 14 health indicators, and medications per person in Australia, Belgium, Canada, Denmark, Finland, Germany, Netherlands, Spain, Sweden, United Kingdom, United States

defining primary care
Defining Primary Care

“The provision of integrated, accessible health care services by clinicians who are accountable for addressing the large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”

Institute of Medicine: Primary Care: America’s Health in a New Era, Washington DC: National Academy Press, 1996

what we want from primary care
What We Want from Primary Care
  • A relationship with our providers that crosses settings, time, & place
  • Caring, compassionate interactions
  • Coordination & integration of care across providers
  • Ability to access care 24/7 – when & where we need it
  • Time, time, time…
what do we get
What Do We Get?

The 15 minute visit!

why follow the money
Why? Follow the Money!


  • What we want:
  • Relationship with our providers
  • Caring, compassionate interactions
  • Coordination & integration of care
  • Ability to access care 24/7
  • Time, time, time…
  • What we pay for:
  • Visits
  • Tests
  • Procedures
  • Procedures
  • Procedures
the stalemate that blocks change
The Stalemate that Blocks Change

Employers & payers unwilling to pay for desired services unless primary care demonstrates value AND create potential to save money

Providers unable to transform practice without viable & sustainable payment for desired services


the medical home a model for change
The Medical Home: A Model for Change!

Providers transform practice, create value with viable & sustainable payment for desired services

= Practice Transformation

Employers & payers pay for desired services because primary care demonstrates value AND saves money

= Payment Reform


breaking the stalemate
Breaking the Stalemate

PCMH recognizes need, supports BOTH…


  • Practice Transformation to give us what we want…
  • Relationship with our providers
  • Caring, compassionate interactions
  • Coordination & integration of care
  • Ability to access care 24/7
  • Payment Reform to pay providers for …
  • Time for caring, compassionate interactions
  • Coordination & integration of care, care management
  • Access to care 24/7
  • Information systems needed to integrate care
  • Population health management
defining medical home
Defining Medical Home

“A medical home is not a building, house, or hospital, but rather an approach to providing comprehensive primary care. A medical home is defined as primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.”

American Academy Pediatrics

medical home background
Medical Home - Background
  • Concept first introduced by AAP in 1964 – children with special health care needs
  • AAFP “New Model” of family medicine – 2004
  • Tested in “National Demonstration Project” (TransforMED) - 2006-2008
  • AAP, ACP, AAFP, AOA together draft “PCMH Joint Principles” - 2007
  • Partner with health plans, employers, CMS in “Patient Centered Primary Care Collaborative”
  • Emergence of multi-stakeholder pilots across country
aafp aap acp aoa pcmh joint principles
  • Every patient has a personal physician
  • Care is provided by a physician-directed team who collectively care for patient
  • Personal physician is responsible for providing all patient’s needs, or arranging for services to be provided by others
  • Care is coordinated and integrated across all aspects of healthcare system
aafp aap acp aoa pcmh joint principles18
  • Quality and safety are hallmarks of PCMH
    • Evidence-based guidelines and tools guide care
    • Practice regularly assess its quality of care
  • Patients are offered enhanced access to care (e.g. expanded hours, enhanced communication options)
  • Payment appropriate recognizes added value of PCMH
pcmh emergence of multi payer pilots
PCMH-Emergence of Multi-Payer Pilots


Multi-Payer pilot discussions/activity

Identified pilot activity

No identified pilot activity

maine pcmh pilot leadership
Maine PCMH Pilot Leadership

Maine Quality Forum

Quality Counts

Maine Health Management Coalition

maine multi payer pcmh pilot
Maine Multi-Payer PCMH Pilot
  • Led by neutral multi-stakeholder collaborative – MQF, QC, MHMC, open to all interested
  • Participation of 4 major private payers & MaineCare
  • Established mission & vision, guiding principles for Maine PCMH model
  • Pending funding resources…,
    • Will select 10-20 pilot practices across state
    • Will provide shared resources to support practice transformation
    • Will develop framework to promote shared learning across & beyond pilot practices
maine multi payer pilot status
Maine Multi-Payer Pilot Status

PCMH Working Group – work to date:

  • Secured initial funds for planning process
  • Est’d Maine PCMH model thru mission & vision, Maine PCMH Guiding Principles
  • Est’d criteria, threshold for practice site participation
  • Dev’d initial framework for pilot evaluation
  • Dev’ing specific expectations practice participation (MOA)
  • Dev’ing criteria, method for selecting practice pilots
maine multi payer pilot status23
Maine Multi-Payer Pilot Status

PCMH Working Group – work in progress…

6. More fully identify outcome measures, evaluation plan

7. Dev plan for supporting practice transformation

8. Conduct outreach, communication to key stakeholders, including all PCP practices

9. Identify additional resources to support implementation

maine multi payer payment model
Maine Multi-Payer – Payment Model

MHMC-convened Physician Payment Reform Comm

  • Dev’d principles for payment model
  • Has kept all private payers & MaineCare at table
  • Proposed (9/24) 3-component payment model
    • Prospective (pmpm) care management payment
    • Ongoing FFS payments, possibly with additional payments for previously non-reimbursed services
    • Performance Payment for meeting quality & total cost savings targets – shared savings model
maine pcmh pilot what practices need to know
Maine PCMH Pilot:What Practices Need to Know
      • Criteria for application
        • Maine primary care practice
        • Completed MHIQ c/w Level I NCQA PPC-PCMH
        • Minimum panel size (TBD)
  • Agreements for participating practices (MOA)
    • Identified leadership, full participation of practice team
    • Participation in PCMH Learning Collaborative, QI coaching
    • Tracking, submission of clinical outcomes data
    • Agreement to achieve “Core Commitments” within 12 mos of start
maine pcmh pilot practice core commitments draft
Maine PCMH Pilot Practice “Core Commitments” (DRAFT!)
  • Demonstrated physician leadership
  • Team-based approach
  • Practice-integrated care management
  • Same-day access
  • Behavioral-physical health integration
  • Inclusion of patients & families
  • Connection to community / local HMP
  • Commitment to waste reduction
pcmh opportunities for improving safe prescribing
PCMH & Opportunities for Improving Safe Prescribing
  • Medical home as focal point for coordinating prescribing across providers
  • EMR / registry support
  • Nurse care coordination
  • PCMH Learning Collaborative to offer support on safe prescribing
  • Ultimately… TIME!!
maine pilot issues tbd
Maine Pilot - Issues TBD
  • Will all employers, payers engage in new payment model?
  • Will new payment be enough to support true practice transformation?
  • What criteria for pilot site selection?
  • How to engage specialists, hospitals in shared goals, shared cost savings?
  • How to engage patients in new partnership?
needed to move forward
Needed to Move Forward
  • Engagement, leadership, and dialog among key stakeholders
    • Consumers
    • Physicians, NPs, provider organizations/PHO’s, medical groups
    • Payers – private & public
    • Employers
    • Public health
  • Culture change to create, sustain transformative change
  • Commitment to collaboration!
pcmh creating hope for a better system
PCMH Creating Hope for a Better System

With thanks to Dr. Tom Bodenheimer, Dept. Family & Community Med, UCSF