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


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

The Medical HomeA Model for Health
Reform?February 17, 2009
  • James F. Coan
  • Project Officer, Medicare Medical Home
    Demonstration, Centers for Medicare Medicaid
  • 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

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

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

  • 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

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)

2 Main Parts of the Medical Home
  • The Practice
  • The Physician

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

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

Tier 1 Requirements
  • 14 required capabilities, for example
  • Discuss with patients the role of the medical
  • Establish written standards for patient access
  • Use data to identify/track patients
  • Use integrated care plan
  • Provide patient education/support
  • Track tests/referrals

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

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

Which Practices Are Qualified?
  • Physician-Based practice
  • First point of contact and main source of primary
  • Must be able to provide medical home services
  • Oversee development implementation of plan of
  • Use evidence-based medicine decision-support
  • 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

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

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

Physician Responsibilities
  • Each physician in the Medical Home is expected to
    provide specific services to each patient as
  • 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

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

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)

Which Patients are Eligible/Ineligible?
  • Medicare fee-for-service beneficiaries
  • At least one eligible chronic condition (86 of
  • 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

Location and Sample Size
  • 8 sites (A site is a state or a part of a state.)
  • Will include urban, rural, medically underserved
  • 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

What Are the Benefits to Practices?
  • Care management fee
  • Share in savings
  • Ability to provide better quality care to
  • Improved practice work flow
  • Improved job satisfaction

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
  • Risk-adjusted, based on hierarchical condition
    categories (HCC) score of the patient

What Is the Care Management Fee?
Next Steps
  • Recruitment
  • Notify all practices in demo sites
  • Application
  • Submission of initial application
  • Qualification
  • Beneficiary Enrollment
  • Beneficiary education and agreement

Additional Information/Questions
James F. Coan, Project Officer www.cmsmedicalhome.
Technical Assistancefor the Medicare Medical
Home Demonstration Project
  • Dr. Chad Boult
  • Johns Hopkins Bloomberg School of Public Health
  • February 17, 2009

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

Pay for Performance at DHYour Medical Home
  • Barbara Walters DO, MBA
  • Senior Medical Director
  • Dartmouth - Hitchcock

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

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

CMS Physician Group Practice Demonstration Project
  • The Pre-work ?

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

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
  • We achieved 98 of the quality metrics , so part
    of the above payout was for quality

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

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

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

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

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?

Design and Negotiate the Pilot
Adopted the Joint Principles for Medical Home
  • Personal Physician
  • Physician directed medical practice
  • Whole person orientation
  • Care is coordinated and/or integrated
  • Quality and safety are hallmarks
  • Enhanced access

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
  • Allow for physicians to share in savings from
    reduced hospitalizations
  • Allow for additional payments for achieving
    measureable quality improvements

(No Transcript)
Patient Centered Medical Home Bonus Model
Results to date
  • Began 4-1-09
  • Data clean up our docs?, our patients?
  • Steering Committee and Operational Committee
  • 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

(No Transcript)
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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.
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
nter and
Barbara A. Walters, D.O., M.B.A. Senior Medical
Director Southern NH Community Group
Practices Dartmouth-Hitchcock 603-629-1101 Barbar 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.
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