Proven Innovations in Primary Care Practice

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1 Proven Innovations in Primary Care Practice October 14, 2014 The opinions expressed are those of the presenter and do not necessarily state or reflect the views of SHSMD or the AHA Society for Healthcare Strategy & Market Development

2 Agenda I. Objectives II. III. IV. Changes in the Role of Primary Care Physicians PCMHs and ACOs: Concepts and Results The Evolution from PCMH to Other Models and Approaches V. Questions and Discussion 2

3 CHANGES IN THE ROLE OF PRIMARY CARE PHYSICIANS

4 Traditional Role of the Primary Care Practice One-to-one patient care Managed care interaction and contract negotiation Supervising staff Payment per unit of service 4

5 Evolving Practice Approaches Beyond of the Patient-Centered Medical Home (PCMH) Example Requirements Example Models and Approaches Access Group visits Population health management Care coordination PCP Role (Patient Care) Patient empowerment Telemedicine Wellness Team care Outcomes 5

6 Other Practice Innovations: Beyond the PCMH Concierge practice Patient portals Patient registries Patient empowerment Chronic care approaches Unsponsored patient care management Dedicated house calls Dedicated nursing homes Telephone technology Other (?) 6

7 PCMHs AND ACOs: CONCEPTS AND RESULTS

8 Patient-Centered Primary Care Collaborative Report, January commercial and not-for-profit plans are using the PCMH concept Early evidence showing many consistent, positive outcomes Research also showing the foundational role of PCMHs in other delivery models such as ACOs, with high-performing ACOs embracing their strong PCMH components Substantial improvements demonstrated in cost, utilization, population health management, prevention, access to care, and patient satisfaction Source: The Patient-Centered Medical Home s Impact on Cost & Quality: An Annual Update of the Evidence, , The Patient-Centered Primary Care Collaborative, January

9 Recent Findings on PCMH Results Total Studies S Cost Reductions Fewer ED Visits Fewer Inpatient Admissions Fewer Readmission s + Improvement in Population Health Improved Access Increase in Preventive Services Improvement in Satisfaction Peer-Review/Academia Reported outcomes (n = 13) 61% (n = 8) 61% (n = 8) 31% (n = 4) 13% (n = 1) 31% (n = 4) 31% (n = 4) 31% (n = 4) 23% (n = 3) Industry Reports Reported outcomes (n = 7) 57% (n = 4) 57% (n = 4) 57% (n = 4) 29% (n = 2) 29% (n = 2) 14% (n = 1) 29% (n = 2) 14% (n = 1) Source: The Patient-Centered Medical Home s Impact on Cost & Quality: An Annual Update of the Evidence, , The Patient-Centered Primary Care Collaborative, January

10 Individual PCMH Results BCBS of California ACO Pilot 15% fewer hospital readmissions 15% fewer inpatient hospital stays 50% fewer inpatient stays of 20 days or more Overall health care cost savings of $15.5 million Capital Health Plan 40% fewer inpatient stays 37% fewer ER visits 250% increase in primary care visits 18% lower health care claims costs BCBS of Michigan 13.5% and 10% fewer ED visits among children and adults 7.5% lower use of high-tech radiology 17% lower ambulatory-care sensitive inpatient admissions 6% lower readmission rates 60% better access to care for practices open 24/7 Health Partners 39% lower ER visits 40% lower readmission rates Reduced appointment wait time from 26 to 1 day 129% increase in optimal diabetes care Source: accessed January

11 Individual PCMH Results (continued) BCBS of New Jersey (Horizon BCBSNJ) 10% lower per member per month costs 26% fewer ED visits 25% fewer hospital readmissions 21% fewer inpatient admissions Geisinger Health System 25% lower hospital admissions 50% lower readmissions following discharge Longer exposure to medical homes reduces health care costs: BCBS of South Carolina % lower inpatient hospital days 25.9% fewer ED visits 6.5% lower per member per month medical and pharmacy costs Source: accessed January

12 What they are Accountable Care Organizations: The Basics CMS/CMMI-developed payment and delivery model pilots Commercial payor arrangements organized in a structure similar to CMS/CMMI structures Group of payors, physicians, hospitals, and other providers that collaborate (legal entity) to provide efficient, highquality, and coordinated care to assigned patient population(s) across a range of care settings If providers reduce costs and/or improve established quality metrics in a given time frame, they are eligible to share in associated savings with payors/at risk with payors What they are not Fast facts Health care reform and/or population health management Patient-centered medical home Value-based purchasing Bundled payments Clinical integrated networks Physician groups lead the greatest proportion of ACOs, followed by health systems 52% of Americans live in a service area with at least one ACO Medicare ACOs represent 52% of all ACOs ACOs cover approximately 40 million patients, with nearly 500 health care entities practicing accountable care ACOs are projected to save Medicare up to $940 million in the first four years Sources: Growth and Dispersion of Accountable Care Organizations, Leavitt Partners, June ACO Manifesto: 50 Things to Know About Accountable Care Organizations, Becker s Hospital Review, September

13 CASE STUDY: ADIRONDACK HEALTH INSTITUTE

14 Adirondack Health Institute Providers Payers 97 physicians and 127 MLPs spanning 33 individual practices All 7 commercial payors, Medicare, Medicaid Hospitals Adirondack Medical Home Pilot Patients 5 hospitals and health systems Population 200, ,000 patients attributed 14

15 Adirondack Medical Home Pilot Five-year pilot to generate health care value in Adirondacks Key objective is to transform physician practices into NCQA recognized medical homes Launched in January 2010 Source: Three operational pod support structures covering over 8,000 square miles 15

16 Evolution of the PCMH to Other Models 1. Health Home 2. Practice Innovations 3. Care Transitions Program 4. Health Innovation Plan Significant changes in primary care practice 16

17 #1 Health Home Health Home: roots in Affordable Care Act Health Home model expands on the medical home model to build linkages to other community and social supports, and to enhance coordination of medical and behavioral health care, with the main focus on the needs of persons with multiple chronic illnesses. Source: 17

18 Broad Criteria for Health Home: Integration At least two chronic conditions, one chronic condition and at risk for another, or one serious and persistent mental health condition Chronic Conditions: Mental health condition (SED excluded initially) Substance abuse disorder Asthma Diabetes Heart disease BMI over 25 HIV/AIDS Hypertension 18

19 Health Home Network Partners Primary Care Specialty Care Hospitals Care Management Home Health Care Payors Behavioral Health Providers Substance Abuse Treatment Providers Psychiatric Hospitals Housing Transportation Other Social Services & Community Supports 19

20 #2 Practice Innovations: Deploying Population Health Management Resources Prioritize Care Manager Activity Based On Potential for Impact Chronic disease management Education & counseling Care plan creation Care transition to home Care Managers Primary care visit 5-7 days post discharge Medication reconciliation Early warning sign awareness Caregiver/Home Health/DME in place Care transition to post acute care Continuity of care to post-acute care facility Communication of care plan ED diversion programs Ensure primary care access Optimize urgent care access Leverage ED diversion program 20

21 #3 Care Transitions Program (CMS) Consortium of six community-based organizations and 10 hospitals serving over 100,000 FFS Medicare beneficiaries in a 10-county region AHI will coordinate the care transitions intervention discharge process at three partner hospitals 21

22 #4 New York State Health Innovation Plan Build upon the experience of regional health care innovation models including those of AHI (Adirondack Medical Home Pilot, Health Home) that have made significant contributions toward achieving the triple aim for all New Yorkers Empower regional entities that are best equipped to set local priorities, convene local stakeholders, and support mechanisms of regional implementation to lead plan implementation 22

23 New York State Health Innovation Plan There are five strategic pillars Improving access to care for all New Yorkers, without disparity Integrating care to meet consumer needs seamlessly Making health care cost and quality transparent to enhance consumer decision making Paying for value, not volume Strengthening linkages among primary care, community resources, and policies for health improvement There are three enablers that are foundational to all strategies Health care workforce strategy Health information technology Measurement and evaluation 23

24 Business as Usual Is Not Sustainable Health care delivery systems are being transformed based on patient needs and workforce availability Issues considered: New models of care, like the PCMH Collaborations across providers Effective strategies for chronic disease management Innovative staffing configurations Worker flexibility Evaluate outcomes and adjust as needed Source: 24

25 Accomplishments Improved patient and physician satisfaction Stabilized primary care system Achieved specific gains in quality indicators Lowered cost by reductions in ER visits and inpatient stays 25

26 Today s Challenges Continued threat of physician and primary care provider shortages Fragmented, widely dispersed services Need to transition medical, behavioral, and long-term care services to outpatient settings ADK Medical Home Pilot ends

27 Pilot & AHI and Other Regional Initiatives = ACO Building Blocks Clinical Integration (CI) Pilot serves as an active and ongoing program to evaluate and modify practice patterns by physician participants and create a high degree of interdependence and cooperation among physicians to control costs and ensure quality in health care Quality measures include process compliance, clinical outcomes, and satisfaction Payment reform to reward value rather than volume AHI provides the critical tools for CI and ACO success Health information technology Data analytics Care management Physician leadership 27

28 QUESTIONS AND DISCUSSION 28

29 PRESENTER BIOS 29

30 Presenter Profile Craig E. Holm, FACHE, is senior vice president with Health Strategies & Solutions, Inc., and one of the nation s leading experts on physician-hospital affiliations. With over 30 years of health care administration and consulting experience, he is an expert in primary care strategy, physician-hospital alignment, medical staff planning, and ambulatory care planning. His ability to understand the key issues facing providers has enabled him to evaluate and develop numerous successful physician-hospital alliances including joint ventures that create value for physicians and the sponsoring hospital or system. Craig has also helped hospitals and medical staff organizations develop incentives for active physician participation and facilitate thriving referral relationships, and he is skilled at identifying and implementing revenue enhancement and operations improvement opportunities. Craig is a frequent speaker for national and state health care associations and societies. He has authored two books on the topic of physician-hospital alignment, as well as several articles for leading health care journals and publications. 30

31 Presenter Profile Martin Lipsky, M.D., is an expert in primary care and assists HS&S client organizations with developing strategies for more robust and effective primary care networks. He possesses strong physician management skills and has served as director of multiple clinical programs and a residency program. He is currently dean of the University of Illinois, College of Medicine at Rockford. Martin also previously served as chair of professor and chair, Department of Family Medicine, Northwestern University Medical School and Evanston-Glenbrook Hospitals. As a physician himself, Martin brings strong empirical knowledge of family medicine and physician practices, academic medical centers, and physician-hospital alignment to HS&S client projects. 31

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