The Medical Home: A Model for Health Reform? February 17, 2009

1
The Medical HomeA Model for Health
Reform?February 17, 2009

• James F. Coan
• Project Officer, Medicare Medical Home
  Demonstration, Centers for Medicare Medicaid
  Services
• Dr. Chad Boult
• Professor of Public Health, Director, Lipitz
  Center for Integrated Health Care, Department of
  Health Policy and Management, Bloomberg School of
  Public Health, Johns Hopkins University
• Dr. Barbara Walters
• Senior Medical Director, Dartmouth-Hitchcock
  Medical Center
• Moderator Laurel Sweeney
• Sr. Director, Reimbursement Legislative
  Affairs, Philips Healthcare

2
MEDICARE MEDICAL HOME DEMONSTRATION (MMHD)
OVERVIEW

• James Coan, Project Officer
• Centers for Medicare Medicaid Services
• Baltimore, MD

3
Authorization

• Tax Relief and Health Care Act (TRHCA) of 2006,
  Section 204
• Medicare Improvements for Patients and Providers
  Act (MIPPA) of 2008, Section 133

4
Specifics

• 3-Year Demonstration
• No more than 8 States
• Physician-Based Practices
• High-Need Population
• Individuals with chronic illnesses that require
  regular medical monitoring, advising, or
  treatment.

5
Demonstration Design

• Reviewed statutes, literature (especially of the
  American Academy of Family Physicians (AAFP),
  American Academy of Pediatrics (AAP), American
  College of Physicians (ACP), and American
  Osteopathic Association (AOA)), and experiences
  of others
• CMS consulted with ACP, AAFP, and American
  Geriatrics Society (AGS) and others
• Medicare Medical Home Demonstration design
• Physician Practice Connection (PPC-PCMH-CMS)
• AMA/Specialty Society Relative Value Scale Update
  Committee (RUC) estimated work, office, and
  professional liability insurance expenses to
  establish relative value units (RVU)

6
2 Main Parts of the Medical Home

• The Practice
• The Physician

7
Medical Home Designation

• Medical Home is a term that applies to a
  physician-based practice.
• Has necessary capabilities in place
• Practice culture supports Medical Home type care
• Is committed to coordinating/managing all patient
  care

8
Tier Structure

• Two tiers of medical homes
• Tier 1 Typical medical home services
• Tier 2 Enhanced medical home services
• Both Tiers are fully functional and qualified

9
Tier 1 Requirements

• 14 required capabilities, for example
• Discuss with patients the role of the medical
  home
• Establish written standards for patient access
• Use data to identify/track patients
• Use integrated care plan
• Provide patient education/support
• Track tests/referrals

10
Tier 2 Requirements

• All Tier 1 requirements
• Plus 4 more including
• Use electronic health record (EHR), certified by
  the Certification Commission on Health
  Information Technology (CCHIT), to capture
  clinical information (for example, blood
  pressure, lab results, status of preventive
  services)

11
Practices That Start as Tier 1 Can Later Apply
for Tier 2

• Practices that choose to qualify as Tier 1
  initially may apply to qualify as Tier 2
  practices in subsequent years
• Complete the PPC-PCMH-CMS
• Provide documentation of Tier 2 capabilities
• Upgrade applications accepted during the last
  3-months of year 1 and year 2
• Additional documentation will reviewed as before
• Once Tier 2 qualification is established, the
  practice can receive the Tier 2 care management
  fee

12
Which Practices Are Qualified?

• Physician-Based practice
• First point of contact and main source of primary
  care
• Must be able to provide medical home services
• Oversee development implementation of plan of
  care
• Use evidence-based medicine decision-support
  tools
• Use health information technology to monitor
  track health status of patients
• Encourage patient self-management Capabilities
  qualify as Tier 1 or Tier 2 as measured by
  PPC-PCMH-CMS Version

13
Participating Physicians

• Work within the Medical Home practice structure
• Provide healthcare management services beyond
  regular medical care
• Quarterback of the healthcare management team

14
Which Physicians Are Eligible?

• MD/DO board-certified
• Doctor of Medicine (MD) or Doctor of Osteopathic
  Medicine (DO) practices providing ambulatory
  health care, including federally qualified health
  centers (FQHCs) and small-, medium-, and
  large-sized practices
• Provide first contact, continuous care, main
  source of primary care
• Eligible General internist, family practice,
  geriatrics, some specialties
• Not eligible Radiology, pathology,
  anesthesiology, dermatology, ophthalmology,
  emergency medicine, chiropractors, psychiatry,
  and surgery

15
Physician Responsibilities

• Each physician in the Medical Home is expected to
  provide specific services to each patient as
  necessary
• Provide ongoing support, oversight, and guidance
  through a health care team
• Provide integrated coherent planning for ongoing
  medical care including communication and
  coordination with other physicians and healthcare
  professionals furnishing care
• Provide development and/or revision of documented
  care plans, including integration of new
  information and/or adjustment of medical therapy

16
Physician Responsibilities(cont.)

• Track hospital, and other facility admissions,
  with appropriate follow-up after discharge
• Oversee and track medication changes initiated by
  pharmacy benefit plans
• Provide reconciliation of medications to avoid
  interactions or duplications.
• Review medication changes occurring outside of
  their own E/M visit, including all prescriptions
  and related communication with other physicians
  and health care professionals.
• Review reports of patient status from other
  physicians or health care professionals

17
Physician Responsibilities(cont.)

• Review results of laboratory and other studies
• Monitor staff to ensure the use of evidence-based
  medicine and clinical decision support tools to
  facilitate diagnostic test tracking, pre-visit
  planning, and after-visit/test follow-up
• Maintain communication (including telephone
  calls, secure web sites, etc.) with the patient,
  family, and caregivers for purposes of assessment
  or care decisions
• Use patient self-management plan (including
  end-of-life planning, home monitoring)

18
Which Patients are Eligible/Ineligible?

• Medicare fee-for-service beneficiaries
• At least one eligible chronic condition (86 of
  beneficiaries)
• Based on the adapted Hwang et al. list (Health
  Affairs 2001) on CMS website
• At Enrollment
• Part A and Part B coverage
• Medicare is primary insurance provider
• Ineligible
• Medicare Advantage
• Hospice
• Long-term nursing home
• Treatment for end-stage renal disease

19
Location and Sample Size

• 8 sites (A site is a state or a part of a state.)
• Will include urban, rural, medically underserved
  sites
• CMS announce sites following approval
• Sample across all 8 sites (not each site)
• 400 practices (small, med. large, FQHC, RHC, CHC)
• 2,000 physicians
• 400,000 Medicare beneficiaries

20
What Are the Benefits to Practices?

• Care management fee
• Share in savings
• Ability to provide better quality care to
  patients
• Improved practice work flow
• Improved job satisfaction

21
What Is the Care Management Fee?

• Based on RUC relative value units for physician
  work, practice expenses, and professional
  liability insurance
• In addition to activities already reimbursed by
  Medicare
• Risk-adjusted, based on hierarchical condition
  categories (HCC) score of the patient

22
What Is the Care Management Fee?
23
Next Steps

• Recruitment
• Notify all practices in demo sites
• Application
• Submission of initial application
• Qualification
• PPC-PCMH-CMS
• Beneficiary Enrollment
• Beneficiary education and agreement

24
Additional Information/Questions
James F. Coan, Project Officer www.cmsmedicalhome.
org medhomedemo_at_cms.hhs.gov
25
Technical Assistancefor the Medicare Medical
Home Demonstration Project

• Dr. Chad Boult
• Johns Hopkins Bloomberg School of Public Health
• February 17, 2009

26
Technical Assistance

• Guided Care implementation manual
• On-line course for Guided Care nurses
• On-line course for physicians
• Guidance in selecting HIT
• Online practice self-assessment (MHIQ)
• Webinars, learning collaboratives, networks
• Information by Internet and telephone
• Consultation

27
Pay for Performance at DHYour Medical Home

• Barbara Walters DO, MBA
• Senior Medical Director
• Dartmouth - Hitchcock

28
Dartmouth-Hitchcock

• Dartmouth- Hitchcock clinic
• Mary Hitchcock Memorial Hospital
• Dartmouth Medical School
• VA Medical Center in White River Junction
• Dartmouth-Hitchcock Alliance

29
Dartmouth-Hitchcock Operations

• 1,500,000 outpatient visits per year
• 21,000 inpatients
• 1000 physicians
• 7500 employees
• 900 medical students, residents fellows
• Reimbursement environment All FFS
• EMRs data warehouse

30
CMS Physician Group Practice Demonstration Project

• The Pre-work ?

31
CMS Demonstration Project

• 10 multispecialty groups
• FFS Medicare Environment
• Assignment of patients done retrospectively based
  on preponderance of care
• Responsibility for total cost of care
• Bonus allocated for cost savings first then
  quality

32
CMS Results

• We achieved savings in year 1 , but did not meet
  the threshold for bonus payment
• We achieved all quality metrics in year one
• We achieved savings and passed the threshold in
  year 2, so received 6.8 million dollars of bonus
  payouts
• We achieved 98 of the quality metrics , so part
  of the above payout was for quality

33
Most Important Clinical Interventions

• ICD 9 Coding Training
• Transform the role of the RN health coaches,
  and pre-visit planning
• Registry Development
• Post Discharge Phone Call

34
Where did we see a difference?

• Our risk adjusted total cost was lower than the
  comparison group we had significantly sicker
  patients who we cared for more efficiently
• Our admission rate for all of our patients was
  lower than our comparison group
• The cost of care of our CHF patients was less
  than out comparison group
• Our quality was better than the comparison group

35
Cigna Project

• The CMS project was successful so we began
  looking for a Commercial plan to partner with to
  apply our clinical model to that population

36
Improve on the CMS model

• Attribution was for primary care providers only
• First dollar savings
• Quality metrics for clinical conditions in
  control of the primary care dept.
• Ongoing payment for care management biggest
  issue for implementation!
• Bonus methodology needs to include employer
  groups especially self-funded, so most of the
  practice s patients are included..
• Create a preferred environment for primary care
  doctors to practice

37
Commercial Plans Additional Concerns

• Access-Access-Access
• ER usage still high
• Gaps in care , especially for preventative visits
• Employer Groups and self-funded plans need early
  results to sign on
• Health plans have disease management initiatives
  how to collaborate?

38
Design and Negotiate the Pilot
39
Adopted the Joint Principles for Medical Home
Designation

• Personal Physician
• Physician directed medical practice
• Whole person orientation
• Care is coordinated and/or integrated
• Quality and safety are hallmarks
• Enhanced access

40
Adopted Reimbursement Principles

• Reimbursement should
• Reflect the value of non-face time
• Pay for care coordination
• Support adoption and use of HIT for QI
• Support enhanced communication such as secure
  email and telephone consultation
• Allow for separate fee-for-service visit payment
• Recognize case mix differences in patient
  population
• Allow for physicians to share in savings from
  reduced hospitalizations
• Allow for additional payments for achieving
  measureable quality improvements

41
(No Transcript)
42
NCQA PPC-PCMH
43
NCQA PPC-PCMH
44
Patient Centered Medical Home Bonus Model
45
Results to date

• Began 4-1-09
• Data clean up our docs?, our patients?
• Steering Committee and Operational Committee
  structure
• Received Baseline performance year data
• Working on gaps in care
• Identifying patients who need case management
• Continue enhancing the Medical Home Practice
  Model in each of our 48 sites
• GREAT collaboration !! too early for results

46
(No Transcript)
47
Questions
48
Tell us what you think

• Please go to http//www.tinyurl.com/philips217
  to complete a quick survey on this session.
• If you have suggestions for new webinars, please
  note them on the survey.

49
Jim Coan Social Science Research Analyst Office
of Research Development and Information Centers
for Medicare and Medicaid Demonstrations Jim
Coan is a Social Science Research Analyst in the
Demonstrations Program Group of the Office of
Research Development and Information in the
Centers for Medicare and Medicaid Services. The
majority of Jims experience, however, comes from
the world of public health as a Senior Public
Health Advisor for 22 years with the Centers for
Disease Control and Prevention. During that time
Jim has worked extensively in the areas of
communicable disease prevention, vaccine
preventable diseases, and chronic disease
prevention at the local, state, and national
levels. He also has worked abroad in Southeast
Asia with Indochinese refugees. Throughout
his career, Jim has developed an extensive
background in research design methodologies and
coverage and payment systems, as well as in
social marketing and health promotion and disease
prevention approaches. Jim came to CMS in 1995
and now devotes his skills and experience to
conducting research demonstration projects for
Medicare and Medicaid populations. Jim is the
Project Officer for the Medicare Medical Home
Demonstration Project.
50
Chad Boult, MD, MPH, MBA Eugene and Mildred
Lipitz Professor Director of the Roger C. Lipitz
Center for Integrated Health Care Department of
Health Policy and Management Johns Hopkins
Bloomberg School of Public Health Dr. Chad Boult
is the Eugene and Mildred Lipitz Professor of
Health Policy and Management at the Johns Hopkins
Bloomberg School of Public Health. He directs the
Roger C. Lipitz Center for Integrated Health Care
and holds joint appointments on the faculties of
the Johns Hopkins University Schools of Medicine
and Nursing. The mission of the Lipitz Center is
to improve the health and quality of life for
people with complex health care needs by
conducting research and disseminating new
knowledge. The Center is also committed to
preparing the next generation of leaders in this
field. Dr. Boult advises multiple masters,
doctoral, and post-doctoral students and teaches
two graduate-level courses Innovations in
Health Care for Aging Populations, and New
Frontiers in Gerontology. A geriatrician for
more than 17 years, he has extensive experience
in developing, testing, evaluating, and diffusing
new models of health care for older persons. His
current research includes Guided Care, a novel,
multi-disciplinary model of primary care for
older people with multiple chronic conditions.
Guided Care is designed to improve the quality
and outcomes of complex health care by improving
the delivery systems design, decision support,
access to clinical information, support for
self-management, and by facilitating patients
access to community services. Dr. Boult is the
Principal Investigator of a multi-site,
cluster-randomized controlled trial of Guided
Care involving 48 physicians, 933 older patients,
and 319 family members in the Baltimore-Washington
DC area. The study is funded by a public-private
partnership of the Agency for Healthcare Research
and Quality, the National Institute on Aging, the
John A. Hartford Foundation, and the Jacob and
Valeria Langeloth Foundation. As an expert on
chronic care, Dr. Boult has spoken at meetings
and conferences throughout the world. He has
published projections of the number of disabled
older Americans in the 21st century and numerous
studies of the outcomes of innovative models of
health care for older persons. He created the
first validated instrument for identifying
high-risk older persons (the Pra) and co-edited a
book entitled New Ways to Care for Older People
Building Systems Based on Evidence Springer
Publishing Company, 1999. He received the
Excellence in Research Award from the American
Geriatrics Society in 2000. From 2000-2005 he
edited the Models and Systems of Geriatric Care
Section of the Journal of the American Geriatrics
Society. He has reviewed manuscripts submitted to
many scientific journals and grant proposals
submitted to the National Institute on Aging, the
Agency for Healthcare Research and Quality, and
several foundations. When time allows, he
provides consultation to health care
organizations that seek to improve health care
for persons with chronic conditions. Additional
information is available at www.jhsph.edu/LipitzCe
nter and www.GuidedCare.org
51
Barbara A. Walters, D.O., M.B.A. Senior Medical
Director Southern NH Community Group
Practices Dartmouth-Hitchcock 603-629-1101 Barbar
a.A.Walters_at_Hitchcock.org Dr. Barbara Walters,
Senior Medical Director for Dartmouth-Hitchcocks
Southern New Hampshire Community Group Practices,
is responsible for management of ambulatory
practice operations located in 15 locations,
employing 1,200 employees, 300 providers, and
providing 1,000,000 visits per year. In addition
she is responsible for commercial payor
contracting for the Dartmouth-Hitchcock system
and is the principal investigator for the CMS PGP
Demonstration Project. Board certified in
psychiatry and neurology, Dr. Walters came to
Dartmouth-Hitchcock in 1998 from the Carolina
Permanente Medical Group in Chapel Hill, North
Carolina, with extensive experience in group
practice and managed care. She earned her
medical degree from Michigan State University,
completed her internship in Family Practice at
Lansing General Hospital in Lansing, Michigan,
and her psychiatric residency at the University
of North Carolina, Chapel Hill. Dr. Walters
received her M.B.A. degree from Duke University
in 1998.