Animated Short: The Amazing Health Care Arms
-participant will understand/be able to discuss the important trend
of PCMH in health care
-participant will understand/be able explore the rationale and
supporting evidence for PCMH
- participant will understand/be able understand the impact on
patients, providers and payers
– I am a full time Emplyee of IBM I WILL NOT discuss any
pharmaceuticals, medical procedures, or devices
I have gratefully had my expenses covered to do some of my talks
about PCMH by Merck, and Pfizer.
The Cause? Mostly due to unregulated fee-for-service payments and an over reliance on
rescue/specialty care. This is stark evidence that the U.S. health care Industry has been
failing us for years “Commonly cited causes for the nation's poor performance are not to
blame - it is the failure of the deliver system!!”
- Unaccountable Care Organizations
* Peter A. Muennig and Sherry A. Glied Health Affairs Oct. 7, 2010
The EMPIRE (of HIGH Hospital cost) State
New York spends more than twice the national average
on Health Care on a per capita basis
New York ranks 22nd out of all states for overall health
Ranks last 50th of 50 for all states for avoidable hospital
use and costs.
Real Transformation must
be pursued in collaboration
across the buyers and payers
Employers, State, CMS, Medicaid.
Change of convenient between
buyers and providers
Why Innovate Affordability
The Elephant in the room
Costs continue their upward climb…
$25,000 …with employers still picking up much of the tab…
2001 2009 2019
- Employer Cost - Employee Payroll Contributions - Employee Out of Pocket Expenses
Slide From Dr Martin Sepulveda
Health care is a business issue,
not a benefits issue
Slide From Dr Martin Sepulveda
OUR IBM Patient needs A long-term
comprehensive relationship with a
Personal Physician empowered with the
right tools and linked to their care team.
The Joint Principles: Patient Centered Medical Home
Personal physician - each patient has an ongoing relationship with a personal
physician trained to provide first contact, and continuous and comprehensive care
Physician directed medical practice – the personal physician leads a team of
individuals at the practice level who collectively take responsibility for the ongoing
care of patients
Whole person orientation – the personal physician is responsible for providing for
all the patient’s health care needs or arranging care with other qualified
Care is coordinated and integrated across all elements of the complex
healthcare community- coordination is enabled by registries, information
technology, and health information exchanges
Quality and safety are hallmarks of the medical home-
Evidence-based medicine and clinical decision-support tools guide decision-making;
Physicians in the practice accept accountability voluntary engagement in
performance measurement and improvement
Enhanced access to care is available - systems such as open
scheduling, expanded hours, and new communication paths between patients, their
personal physician, and practice staff are used
Payment appropriately recognizes the added value provided to patients who
have a patient-centered medical home- providers and employers work together to
achieve payment reform
The Quadruple Aim
Readiness, Experience of Care, Population Health, Cost
Health Cost The System Integrator
System Integrator Creates a partnership
across the medical
Patient Productivity neighborhood
Drives PCMH primary
Offers a utility for
population health and
36.3% Drop in hospital days
32.2% Drop in ER use
-9.6% Total cost (Mayo Zero cost increase)
10.5% Inpatient specialty care costs are down
18.9% Ancillary costs down
15.0% Outpatient specialty down
Outcomes of Implementing Patient Centered
Medical Home Interventions: A Review of the Evidence
from Prospective Evaluation Studies in the US,
K. Grumbach & P. Grundy, November 16th 2010
Every country starts at the base of the pyramid with
Wellness Prevention primary care, and they work
their way up until the money runs out.
2 Care wrong
picture? 1 Care
1 Care, Wellness
… “We start at the top of the pyramid, and we work
our way down until the money runs out…And so we
have to change the pyramid. We have to start at the
Don’t handle your care needs in a BAD MEDICAL NEIGHBORHOOD!!
Unaccountable care, lack of organization, DO NOT GO THERE ALONE !!
Be wise when you pay for care, KNOW WHAT YOU BUY!!
Coordination -- we do NOT know how to play
as a team
“ We don't have a health care delivery system in this country. We
have an expensive plethora of uncoordinated, unlinked, micro
systems, each performing in ways that too often create sub-optimal
performance, both for the overall health care infrastructure and for
individual patients." George Halvorson, from “Healthcare Reform Now
Trajectory to Value Based Purchasing:
Achieving Real Care Coordination and
Value/ Tied to
Outcome Performance on
Measurement: Value (quality,
Reporting of appropriate
Operational Quality, utilization and
Care Utilization and patient
Coordination: Patient satisfaction)
Embedded RN Satisfaction
Primary Coordinator Measures
Care and Health
Capacity: Plan Care Achieve
Patient Coordination $ Supportive Base
Centered for ACOs and
HIT Medical Bundled
Infrastructur Payments with
e: EHRs and Outcome
Connectivity Measurement and
HEALTH INDUSTRY -- WSJ WellPoint's New Hire.
What Is Watson?
IBM – WellPoint
And the PLAN is – CPCi by CMMI
Care management: Primary care practices will be able to proactively
assess their patients to determine their needs and provide
appropriate and timely preventive care.
Access and continuity: Primary care practices must be accessible to
patients on a 24/7 basis and be able to utilize patient data tools to
give real-time healthcare information to patients in need.
Planned care for chronic conditions and preventive care:
Participating primary care practices will deliver intensive care
management for the patients with high needs and create a plan of
care that fits a patient’s individual circumstances and values.
Patient and caregiver engagement: Primary care practices will have
the ability to actively engage patients and their families to participate
in their care.
Coordination of care across the medical neighborhood: WELLBY
Cost of Commercial lives
Least Expensive Most Expensive
Ogden, UT $2,623 Anderson, IN $7,231
Dubuque, IA $2,719 Punta Gorda, FL $7,168
McAllen TX $2,950 Racine, WI $6,528
Naples, FL $6,312
Ocean City, NJ $6,128
OPM $39 Billion Book with Accountable Care
Patient at the Center
24-7 clinician phone response Pre-visit planning and after-
visit follow-up for care
Provide open scheduling. management.
Provide care management and Offer patient self-management
coordination by specially-trained support.
Provide a visit summary to the
Use an EHR with decision support. patient following each visit.
Use CPOE for all orders, test Maintain a summary-of-care
tracking, and follow-up. record for patient transitions.
Medication reconciliation for every Email consultations.
Prescription drug decision support.
The development of care
Implement e-prescribing. plans.
Defining the Care Centered on Patient
“We do kidney transplants and dialysis more often than anyone,
but we need to, because patients are not given the kind of
coordinated primary care that would prevent chronic
complications of renal and heart disease from becoming acute.”
George Halvorson (CEO Kaiser)
from “Healthcare Reform Now”
If you scan the world for value based healthcare, you will find a common
element: a relationship-based team with a project manager!
A comprehensivist that can command and control in an accountable
Payment reform requires more than one
method, you have dials, adjust them!!!
fee for health”
“fee for outcome”
“fee for process”
“fee for belonging
“fee for service”
“fee for satisfaction”
CMS Plus most other buyers
11% CMS Shift in payment away from FFS
to other dials.
CMS Bundling!! CMS Advanced Primary Care
Wellpoint PCMH, BCBS Hawaii no new FFS $$
PCMH in Action
Vermont “Blueprint” model
Hospitals Health System
Community Care Team
Social Workers Health IT
Specialists Dieticians Framework
Community Health Workers
Care Coordinators Global Information
Public Health Prevention
Public Health HEALTH WELLNESS Evaluation
Vermont Financial Impact
IMPACT OF MEDICAL HOME
SAVINGS ACROSS TOTAL POPULATION
1 2 3 4 5
BCBS MA 6% decrees cost (NEJM)
BCBS MI 2670 physician (BIG study)
ER visits -6.6% -9.9%
Primary care sensitive
ER Visits -7.0% -11.4%
1,000) -11.1% -22.0%
And Today in NY PCMH practices
Avoidable emergency room visits continue downward
trend, seven percent better than market.
Following evidence-based medicine continues to
improve, six percentage points better than market.
Medical cost trend is more than seven percentage
points better than market.
$9 PMPM cost savings.
Diabetes is better controlled, will improve long-term
health and lower medical costs.
The Empire State Plan So simple so much
We Developed a better healthcare system starting with
Public Private payers Private payers Joined
Strong Primary care is foundational to a high performing
Additional resources needed to help primary care manage
Learned timely data is essential to success
Learned must build better local healthcare systems
Physician leadership is critical
Improve the quality of the care provided and cost will
and the Patient Experience
Care that is Healthcare
is the center Patient-Centered
Systems of the Care
Support Tools Medical Training
Model adapted from the
NNMC Medical Home
PATIENT CENTERED MEDICAL HOME:
VHA Patient Aligned Care Team
Replaces episodic care based on illness and patient
complaints with coordinated care and a
long term healing relationship
Reinventing Medicaid findings are Outstanding
Oklahoma's patient-centered medical home initiative has reduced
Medicaid costs $29 per patient per year from 2008 to 2010.
Moreover, use of evidence-based primary care, including screening
for breast and cervical cancer, increased.
The Colorado initiative expanded access to care. Before the
initiative, only 20 percent of pediatricians in the state accepted
Medicaid; as of 2010, 96 percent and did and at a lower cost to the
Vermont, inpatient care use and related per-person per-month costs
decreased 21 percent and 22 percent, respectively, from July 2008
to October 2010. ER use and related per-person per-month costs
decreased 31 percent and 36 percent, respectively.
Patient Centered Medical Home in Washington in State Acute care
spending there was 18 percent below the national average.
Inpatient stays per beneficiary were 35 percent below the national
The Bottom Line in Medicaid
PCMH starting to show an impact in access to care, quality, and cost control.
Citation -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes
Show Promising Results," Health Affairs, July 2011 30(7):1325–34.
Patients love to see meaningful information about
themselves and it take IT tools to
If you give patients educational materials with their name on it and
with their data analyzed in it, they will read it, pour over it and discuss
it with you.
If you tear off a generic sheet and give it to them, it often goes in the
waste basket. If you give patients an analysis of their health risk AND
if you include a “what if” scenario, i.e., what will their health risk be if
they make a change; you can prove to them,
“if you the healer make a change, it will make a difference to your
PCMH is non-political – the right POV
for delivery transformation
“We never abandoned advocating new
Models of care. We’ve long pushed folks
to realize that Delivery reform is the key.”
The patient-centered medical home is
“We included the attached
chapter on PCMH in our book.
and have a new publication on
ACOs coming out in January.”
PMPM Payment: Commercial Population
Size Level of PCMH Recognition
(# of patients) Level 1+ Level 2+ Level 3+
< 10,000 $4.68 $5.34 $6.01
10,000 - 20,000 $3.90 $4.45 $5.01
> 20,000 $3.51 $4.01 $4.51
Tier Major Condition Groups Minutes of Work PMPM PMPM Payment
0 None N/A N/A
1 3-Jan 15 $10.14
2 6-Apr 30 $20.27
3 9-Jul 60 $40.54
4 10+ 90 $60.81
Payment Model Component PMPM Payment
Practice transformation cost payments (year 1 $1.67 PMPM
Performance bonus (beginning in year 2) Up to $2.38 PMPM (value based on performance)
Risk-adjustment Up to $1.67 PMPM (only for practices with above average
patient panel risk profiles; amount varies by practice)
Payment Model Component PMPM Payment
Care management payments Up to $2.50 PMPM
Pay-for-performance payments Up to $2.50 PMPM
Payment Model Component PMPM Payment
Practice support payments $1.50 PMPM
Care management payments $0.60 PMPM (ages 0-17)
$1.50 PMPM (ages 18-64)
$5.00 PMPM (ages 65-74)
$7.00 PMPM (ages 75+)
Shared savings Value based on performance 39
Who was the
Away from Episodes
of Care - FFS
If we truly want to understand costs and where they can be reduced
without compromising outcomes, we need to aggregate costs around
the patient. (need a place to do that – that is PCMH)
The way care is currently organized leads to redundant administrative
costs, unnecessary and expensive delays in diagnosis and
treatment, and unproductive time for physicians.
A system integrator a place where data is aggregated, understood and
held accountable at the level of the individual patient -- THAT IS
In fact, cost reduction will often be associated with better outcomes.
The Big Idea: How to Solve the Cost Crisis in Health Care
by Robert S. Kaplan and Michael E. Porter
Sept 2011 Harvard review
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