Evidence about the Role of the Patient Centered Medical Home and Accountable Care Organizations in Improving Quality and Safety Robert L. Phillips, MD, MSPH Director Goals Today img027 Describe the Medical Home and an Accountable Care System Discuss how they can improve quality and safety Examples Accountable to whom? Statistics are people with the tears wiped off --Sir Austin Bradford Hill (1897-1991), Pioneer of the randomized clinical trial IMG_1228 DSCN0270 Dr. Tom McCarthy First Generation America—Father was Royal Ulster Constabulary, came over during the “Troubles” Helped found Health Services Research at NIH Helped found two important Federal Agencies Exiled by President Nixon—learned about other health systems Sometime patient, long time friend Great example of what having too many ‘Goddam Doctors’ can do ~8 doctors in 3 health systems that don’t talk to each other, poor continuity Post-MI not on Beta Blocker due to “allergic reaction” Diabetes, on 4 units insulin nightly (loyalty) Must work to coordinate, get clinic notes, prevent medication ‘creep’ Takes up swimming, loses 20 lbs “loses” diabetes blood pressure easier to control Able to care for his wife (Alzheimer’s) in their home Able to travel to his second home in Ireland DSCN0270 Dr. Tom McCarthy Tom: iatrogenic pneumonia, hospitalized MRSA line infection, hospitalized Accidentally discharged on 2 calcium channel blockers = intermittent heart block Intervention stops pacemaker placement Wrong calcium channel blocker stopped Has a pacemaker implanted Never quite recovers No one accountable, in fact most think they did the right thing mombike MaryLou Werner Mother of 13, lost her husband to colon cancer, went to nursing school to support her family Developed Diabetes mellitus and related renal failure At 82, decided 3x/week dialysis was destroying her quality of life Announced she was going off dialysis Mother’s Day 2006 Her family physician not comfortable, walked away No one accountable Accountable Care Organizations Accountable care organizations (ACOs) seek to have providers to think of themselves as a group with a common patient population, care delivery goals, and performance metrics, rather than as discrete entities financial incentives for broad cost containment and quality performance across multiple sites of care Marsha Gold. Accountable Care Organizations: Will They Deliver? Mathematica Policy Research, inc. January, 2010 MedPAC on ACOs and Patient Centered Medical Homes An ACO is “a set of physicians and hospitals that accept joint responsibility for the quality of care and the cost of care received by the ACO’s panel of patients” The Patient Centered Medical Home is a medical practice that furnishes primary care, conducts care management, has formal quality improvement program, has 24-hour patient access, maintains advance directives, and has a written understanding with each beneficiary that it is the patient’s medical home” MedPAC regards medical homes as building blocks of effective ACOs Medicare Payment Advisory Committee (MedPAC). Accountable Care Organizations. http://medpac.gov/chapters/Jun09_Ch02.pdf. July 10, 2009. PCMH needs the ACO Because the PCMH… Often lacks capital to invest in new models of care Has little direct leverage over other providers and offers no direct incentives to work collaboratively or integrate care other providers will allow not allow their incomes to fall due to reductions in referrals or admissions Rittenhouse D, Shortell SM, Fisher ES. Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform. N Engl J Med 2009; 361:2301-2303 ACO Needs the PCMH Because the ACO… will not succeed without a strong foundation of high-performing primary care Is limited by a shortage of primary care capacity and outdated infrastructure of most primary care practices could accelerate savings and quality through investment in the PCMH model Accountable Care Organization PCMH PCMH PCMH PCMH PCMH PCMH group of providers responsible for the health care of a group of people alignment of incentives and accountability of providers across the continuum of care Accountable Care Organization PCMH PCMH PCMH PCMH PCMH PCMH group of providers responsible for the health care of a group of people alignment of incentives and accountability of providers across the continuum of care Hospital Accountable Care Organization PCMH PCMH PCMH PCMH PCMH PCMH group of providers responsible for the health care of a group of people alignment of incentives and accountability of providers across the continuum of care Community Care Team Evidence: Medical Home, Accountable Care UC San Francisco and Patient Centered Primary Care Collaborative updated their evidence November, 2010 Kevin Grumbach (UCSF) Paul Grundy (IBM) http://www.pcpcc.net/content/pcmh-outcome-evidence-quality UCSF/PCPCC fact sheet Integrated Health System PCMH/ACO experiments 7%+ reduction in total costs (entire cost of primary care for Medicare!!) 16%-24% reduction in hospital admissions 30-40% reduction in emergency department Geisinger, Group Health Cooperative,HealthPartners Most of these in just 2-5 years! UCSF/PCPCC fact sheet Insurance experiments 30%+ reductions in hospitalizations, ER visits vs controls Up to 50% reduction in cost growth vs controls North Carolina Medicaid estimates saving nearly $1 billion in just 6 years UCSF/PCPCC fact sheet Johns Hopkins Guided Care PCMH Model 24% reduction in total hospital inpatient days, 15% fewer ER visits 37% decrease in skilled nursing facility days Annual net savings of $75,000 per nurse care coordinator (Medicare) Genesee Health Plan (Michigan) 50% decrease in emergency department visits 15% fewer inpatient hospitalizations Erie County PCMH Model Estimated savings of $1 million for every 1,000 enrollees XLargeThumb January 2011 Special issue Journal of Ambulatory Care Management JACM special issue HealthPartners enrollees with an established PCMH where they get the majority of their primary care had fewer primary and specialty care visits lower costs for professional fees compared to those who fragmented their care across clinics or medical groups. Patients who had a primary care provider made fewer specialty visits ~ difference of 22,570 specialty care visits per year $2.8 million per year This article helps explain lower costs, better outcomes. Relates what we already know about continuity in primary care to the PCMH Is Consistent Primary Care Within a Patient-Centered Medical Home Related to Utilization Patterns and Costs? Fontaine P, Flottemesch TJ; Solberg LI; Asche SE Improved (medical home) scores associated with significant decreases in total ($2,378/person, 4.4%) costs outpatient ($1,282/person, 3.5%) costs For patients with 11 or more prescriptions Higher functioning PCMHs may lead to reduced costs among the most complex and costly patients Very important linkage—An ACO may need to support/invest in primary care to get to more fully functional PCMH in order to realize best outcomes Relationship of Clinic Medical Home Scores to Health Care Costs. Flottemesch TJ, Fontaine P, Asche Se, Solberg LI JACM special issue www.wellmed.net For-profit primary care clinic network of 23 practices in San Antonio, TX partnered with a Medicare Managed Care Plan. First identified as having unusually high quality measures as part of a practice-based research network www.wellmed.net For-profit primary care clinic network of 23 practices in San Antonio, TX partnered with a Medicare Managed Care Plan. First identified as having unusually high quality measures as part of a practice-based research network Case Study Of A Primary Care Accountable Care Organization WellMed, Medical Management, Inc Robert Phillips, MD, MSPH Svetlana Bronnikov, MS Stephen Petterson, PhD Bridget Teevan, MS Maribel Cifuentes, RN David R. West, PhD AHRQ Task Order: SNOCAP-USA (University of Colorado, Robert Graham Center) HHSA290200710008 Dr. David Lanier: Task Order Officer Case Study Of A Primary Care Accountable Care Organization WellMed, Medical Management, Inc Robert Phillips, MD, MSPH Svetlana Bronnikov, MS Stephen Petterson, PhD Bridget Teevan, MS Maribel Cifuentes, RN David R. West, PhD AHRQ Task Order: SNOCAP-USA (University of Colorado, Robert Graham Center) HHSA290200710008 Dr. David Lanier: Task Order Officer Aim 1: Determine: How A PCMH developed their model Aim 2: Determine if the PCMH Improved health outcomes Aim 3: Determine the incremental in-practice expenses (reduced to a pm/pm) required to operate the patient-centered medical home What Can we Learn From a “Mature” PCMH? WellMed Financials About 10% of total to primary care (30-40% more than straight Medicare) Typical CMS benefit $665 pmpm Enhanced benefits (value added) $20 pmpm Disease Magmnt, etc Overhead & Profit Provider Bonus Program $50 pmpm Approx. $400pmpm $100 pmpm Primary care cap After the insurance company takes a share off the top, ~ $1000-$1200 per person per month flows to WellMed Lots of space In primary care trend is downsizing footprint Big community space for exercise classes, computer classes, nutrition/cooking classes Podiatry, Rheumatology, Dermatology rotate through (Now hiring Cardiology) Free orthopedic shoes fitted onsite Practice setting Med Assistants do most data entry Health Coaches Call patients next day to reinforce care plan Meet with patients (clinic, home, phone) to do behavior change, mental health, care plan Two Disease Mgmt programs for COPD, DM, CHF, CAD—A “complex care” team manages the most fragile, high cost patients intensely Teams With Defined Roles Inpatient Their own case managers and hospitalists (their culture, their plan) Interventions for specific conditions—national award for model Knee Replacement protocol Nursing home teams led by NPs Teams Continued… Very low turnover compared to market Grow their own—able MAs trained and mentored into higher roles Starting an MA school cut usual cost in half (more diversity) Train to their model Two week orientation for new physicians + pairing with best clinicians for shadowing and mentoring Teams Continued… Utilization     Texas Region Medicare WellMed     2006 2008 ER visit rates (%) 28.1 17.8 Hospitalization rates (%) 22.1 14.4 Re-hospitalization rates (30 days) (%) 19.9 13.9 Hospital Bed-Days/1000 2559 1002 JACM.jpg WellMed Quality/Safety Lower hospital utilization--but hospital partner has margins 2-3 x that of traditional Medicare (costs lowered more than revenue, similar to Geisinger) Mortality rate 50% lower than rate for all elderly in Texas Improving preventive care with IT systems that monitor and manage patient population Average physician panel size < 500, backed by robust teams and disease management Up to 140% income bonus 2010 (100% financial, 40% quality) $260k-$550k for a primary care physician Back to 30,000 feet “Reason is six-sevenths of Treason” Thurber Back to 30,000 feet Our patients that have the worst outcomes are the ones we don’t see… People with the worst outcomes are often those who are nobody’s patient… For safety and quality, Accountable Care Organizations will have to get beyond personal health to Population health and eventually…Public health. Back to 30,000 feet Personal health ACO Population health Public health Lessons from other countries UK focus on primary care and populations (Primary Care Trusts) is associated with reduced disparities—still experimenting with both primary care and geography of accountability but they move money to do it Australia creating geographic accountability (Medicare locals) and experimenting with making primary care more robust “Super Clinics” Danes are farther ahead than most The ultimate in population accountability: Avertable Deaths If the entire state had outcomes of reference population, 24.3% of deaths 1990-2006 avoided (delayed) 220,211 deaths 1990-2006. ACO impact on quality and safety Necessary focus on primary care and outpatient disease/complex care management Designing programs to meet patients where they are, make access and behavior change easier, facilitate continuous relationships Continuous feedback to system, clinics, providers Encourage curiosity, innovation, plan-do-study-act cycles System resources for testing solutions (failure is ok) Move to population focus but translate to personal health Develop relationships with public health to solve problems that affect health