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West Virginia wants PCMH Level Care Paul Grundy MD, MPH IBM International Director Healthcare Transformation Paul Grundy, MD, MPH, FACOEM, FACPM IBM Director Healthcare Transformation President Patient Centered Primary Care Collaborative Trip to Denmark July 10 2009

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Who was the Shooter’s Doctor? Away from Episodes of Care - FFS Population management !! Accountability !!

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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 PCMH. 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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Just Out <ul><li>WellPoint End Of Pilots -- Rollout time for PCMH!!! </li></ul><ul><li>BCBS Mi 2670 physician (BIG study) </li></ul><ul><li>CMS CMMI CPCi APC </li></ul>2010 2011 Adults (18-64) ER visits -6.6% -9.9% Primary care sensitive ER Visits -7.0% -11.4% Ambulatory care sensitive Hospitalizations (per 1,000) -11.1% -22.0%

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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 Dubuque , Iowa WV 2011

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Deaths per 100,000 population* U.S. Lags Other Countries: Mortality Amenable to Health Care Source: Adapted from E. Nolte and M. McKee, “Variations in Amenable Mortality—Trends in 16 High-Income Nations,” Health Policy, published online Sept. 12, 2011. The Bottom Line If the U.S. had achieved levels of amenable mortality seen in the three best-performing countries—France, Australia, and Italy —84,300 fewer people under age 75 would have died last year . Instead we focused on Rescue Care

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The West Virginia Plan <ul><li>Strong Primary care is foundational to a high performing healthcare system </li></ul><ul><li>Additional resources needed to help primary care manage populations </li></ul><ul><li>Learned timely data is essential to success </li></ul><ul><li>Learned must build better local healthcare systems (public-private partnership) </li></ul><ul><li>Physician leadership is critical </li></ul><ul><li>Improve the quality of the care provided and cost will come down </li></ul>Sec of HHS Michael Lewis MD PhD Commissioner of Public Health, Marian Swinker, MD, MPH

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WV HEALTH IMPROVEMENT INSTITUTE ADOPTION OF ELECTRONIC HEALTH RECORDS Develop proposed mechanisms to accelerate adoption of electronic health records in West Virginia MEASUREMENT Create a forum of alignment of measures across stakeholders to facilitate reporting SELF MANAGEMENT SUPPORT To align and improve access to resources and best practices to improve the self-activation capacity of all patients EDUCATION OF THE PROVIDER COMMUNITY To develop a system of provider engagement to accelerate Medicaid Transformation and assist physician practices with migration to AMH PAY FOR PERFORMANCE To provide guidance on the deployment of a P4P program as a model for the State QUALITY COLLABORATIONS To support a focused collaboration of key stakeholders on improving quality, building on past initiatives Member Education Healthy Rewards Advanced Medical Homes Advanced Medical Homes Pay 4 Performance Evidenced Based Medicine Health Information Systems Electronic Health Information Provider Technology Incentives OTHER RELEVANT INITIATIVES WV HIN – WVMI - OTHERS

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Electronic Health Records “ A team approach to care…utilizing advanced information systems (including a standardized electronic health record); redesigned, more functional offices, and a whole-person orientation that focuses on quality, safety and care provided in a community context.” 129 Clinicians NCQA certified PCMH practices ( ZERO Morgantown) Advanced Medical Home

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And Today in West Virginia Medical Homes 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. Diabetes is better controlled, will improve long-term health and lower medical costs.

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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!! BEST HEART SURGERY !!!!

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The Quadruple Aim = MU, PCMH & ACO Readiness, Experience of Care, Population Health, Cost Population Health System Integrator Patient Experience The System Integrator Creates a partnership across the medical neighborhood Drives PCMH primary care redesign Offers a utility for population health and Financial management Per Capita Cost Readiness

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The Foundation for population health needs A long-term comprehensive relationship with a Personal Physician empowered with the right tools and linked to their care team.

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The Joint Principles: Patient Centered Medical Home <ul><li>Personal physician - each patient has an ongoing relationship with a </li></ul><ul><li>personal physician trained to provide first contact, and continuous and comprehensive care </li></ul><ul><li>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 </li></ul><ul><li>Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or arranging care with other qualified professionals </li></ul><ul><li>Care is coordinated and integrated across all elements of the complex healthcare community- coordination is enabled by registries, information technology, and health information exchanges </li></ul><ul><li>Quality and safety are hallmarks of the medical home- </li></ul><ul><li>Evidence-based medicine and clinical decision-support tools guide decision-making; Physicians in the practice accept accountability voluntary engagement in performance measurement and improvement </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>

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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 system with DATA!! So simple! So much!

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Powerful Engine for transformation Let me put this in WV terms… Compressive vs Episodic Integrated Accessible Coordinated “ Opportunities to expand access to primary care, build the health care workforce, and improve prevention and quality and attract jobs.” Improve the care of the population while controlling costs A “medical home” for patients, emphasizing primary care and make WV a business destination jobs . Community networks capable of managing recipient care with local systems that improve management of chronic illness in both rural and urban settings

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West Virginia Medicaid and employers –Value based purchasing means <ul><li>holding providers accountable for both the quality and cost of care, through: </li></ul><ul><li>Increased transparency of cost and quality outcomes; </li></ul><ul><li>Rewards for performance; and </li></ul><ul><li>Payment reform. </li></ul><ul><li>Emergency Department Collaborative Care Management Initiative – Reduction ED Cost </li></ul><ul><li>Accountable Communities Initiative -- align financial incentives for those providers to work together to improve value and decrease avoidable costs. </li></ul><ul><li>Leveraging and/or expansion of current initiatives and federal opportunities </li></ul>

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Large Employers Partner With Medicaid CCNC New Game Changer “ Aug. 29 (Bloomberg) -- GlaxoSmithKline Plc is giving its privately insured U.S. workers PCMH level Care Via CCNC health-care network that uses primary care doctors to track patient use of specialists and hospitals. Community Care North Carolina Patient-Centered Medical Home model. It provides a comprehensive, team-based model of healthcare delivery. This model drives out variability by implementing standards for all aspects of primary care services. CCNC team ensures that care is all-inclusive and integrated with all other care provided within our system. Each patient will be assigned to a Medical Home, led by one’s primary care physician. The patient is a part of that team as well as a nurse educator, a care coordinator, and other support staff , all linked into and supporting the patient’s health.

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Reinventing Medicaid with PCMH findings are Outstanding <ul><li>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. </li></ul><ul><li>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 state. </li></ul><ul><li>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 . </li></ul><ul><li>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 average. </li></ul>Citation -- M. Takach, &quot;Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results,&quot; Health Affairs , July 2011 30(7):1325–34. The Bottom Line in Medicaid (AS WV discovered already) PCMH starting to show an impact in access to care, quality, and cost control .

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8 Source: Health2 Resources 9.30.08 Defining the Care Publically available information <ul><ul><li>Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs. </li></ul></ul>

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Medical Home Model Model adapted from the NNMC Medical Home <ul><li>Enhances beneficiary’s relationship with provider </li></ul><ul><li>Includes all service primary care initiatives </li></ul><ul><li>Guiding principles, policy </li></ul><ul><li>Certification criteria (AHRQ modification) </li></ul><ul><li>Governance (formal/informal/advisory) </li></ul><ul><li>Metrics (process and end-state) </li></ul><ul><li>Permits debut of the “comprehensivist” </li></ul>Enhancing Health and the Patient Experience Patient is the center of the Medical Home Population Health Patient-Centered Care Refocused Medical Training Patient & Physician Feedback Advanced IT Systems Access to Care Team-Based Healthcare Delivery Decision Support Tools

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Public Health Prevention Specialists PCMH in Action Vermont “Blueprint” model Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers Care Coordinators Public Health Prevention HEALTH WELLNESS Hospitals PCMH PCMH Health IT Framework Global Information Framework Evaluation Framework Operations A Coordinated Health System Mental health PCMH

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Vermont Financial Impact 2009 2010 2011 2012 2013 Percentage of Vermont population participating 6.7% 9.8% 13.0% 20.0% 40.0% Participating population 42,179 61,880 82,332 127,045 254,852 # Community Care Teams 2 3 4 6 13

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Smarter Healthcare… <ul><li>36.3% drop in hospital days, </li></ul><ul><li>32.2% drop in ER use. </li></ul><ul><li>9.6%, total cost </li></ul><ul><li>10.5%, inpatient specialty care costs are down </li></ul><ul><li>18.9%, ancillary costs down </li></ul><ul><li>15.0%. outpatient specialty down </li></ul>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 16 th 2010.

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Payment reform requires more than one method, you have dials, adjust them !!! MAINE IS !! <ul><li>“ fee for health” </li></ul><ul><li>“ fee for outcome” </li></ul><ul><li>“ fee for process,” </li></ul><ul><li>“ fee for belonging/membership” </li></ul><ul><li>“ fee for service” </li></ul><ul><li>“ fee for satisfaction” </li></ul>

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OPM $39 Billion Book with Accountable Care Patient at the center <ul><li>24-7 clinician phone response </li></ul><ul><li>Provide open scheduling. </li></ul><ul><li>Provide care management and coordination by specially-trained team members. </li></ul><ul><li>Use an EHR with decision support. </li></ul><ul><li>Use CPOE for all orders, test tracking, and follow-up. </li></ul><ul><li>Medication reconciliation for every visit. </li></ul><ul><li>Prescription drug decision support. </li></ul><ul><li>Implement e-prescribing. </li></ul><ul><li>Pre-visit planning and after-visit follow-up for care management. </li></ul><ul><li>Offer patient self-management support. </li></ul><ul><li>Provide a visit summary to the patient following each visit. </li></ul><ul><li>Maintain a summary-of-care record for patient transitions. </li></ul><ul><li>Email consultations. </li></ul><ul><li>Telephone consultations. </li></ul><ul><li>The development of care plans. </li></ul><ul><li>Performance outcome </li></ul><ul><li>measures. </li></ul>

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CMS New Comprehensive Primary Care Initiative Risk-stratified 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 Planned care for chronic conditions and preventive care Patient and caregiver engagement: Coordination of care across the medical neighborhood.

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Where do you train the WV Workforce? There are examples of at least a few &quot;high performing&quot; Health Professional schools that support team based coordinated care delivery SELECT AND SUPPORT THESE … Requires a Smarter Healthcare Workforce OR ?

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Recommendations <ul><li>WVU and WV Start the journey -- build the foundation, the horizontal platform, a place of accountability - PCMH </li></ul><ul><li>WV really engage your patients find out what they need and become very patient centered </li></ul><ul><li>Employers in WV Stop buying from unaccountable care organizations unwilling to transform - Join us </li></ul><ul><li>WV - Stop sending your students to train at UCO’s. </li></ul><ul><li>Set up WV workforce standards for education and training based on guiding principles of PCMH </li></ul><ul><li>Integrate Health and Sick care </li></ul><ul><li>GIVE US LEADERSHIP ----SHOW US THE WAY </li></ul>