Texas Patient Centered Medical Home Demonstration Project

1. Texas Patient Centered Medical Home Demonstration Project Sue S. Bornstein, MD, FACP January 27, 2009

2. Texas Geography – A Review

3. Texas Facts • El Paso is closer to California than to Dallas • The King Ranch in South Texas is larger than Rhode Island • Texas is the only state to enter the US by treaty rather than annexation and reserves the right to divide itself into 5 regions • Texas has had six capital cities • The state animal is the armadillo • At 570 feet, the San Jacinto Monument is 15 feet higher than the Washington Monument

4. More Texas Facts… • Texas is now the second most populous state in the country (estimated 24,000,000 in 2008) • Texas has the highest percentage of uninsured residents - approximately 25% • Texas ranked 49th out of the 50 states in the Commonwealth Fund’s State Scorecard on Health System Performance • 64% of adults and 35% of children are overweight or obese • An estimated 1.4 million adults in Texas have been diagnosed with diabetes • By the next census date, Texas will have a majority Hispanic population

5. Primary Care in Texas • The national average for primary care physicians to every 100,000 people is 81 while Texas averages 68/100,000 • 19 Texas counties have just two physicians; 17 counties have one physician and 25 counties have no physicians at all • ED visits in Texas jumped from 5.5 million in 1992 to 8.6 million in 2003 • People earning more than 400% of the federal poverty level accounted for a growing portion of ED visits • Comprehensive tort reform was enacted in 2003; however, the greatest increase in physicians moving to Texas is in the high-risk specialty areas • Majority of primary care practices are composed of 5 or less physicians

6. Primary Care in Texas • The Primary Care Coalition was formed in 2001 to strengthen the voice of primary care in Texas • Constituent organizations are Texas Academy of Family Physicians; Texas Chapter of the American College of Physicians and Texas Pediatric Society • PCC has published three influential papers on the state of primary care in Texas • They outline the challenges we face and put forward possible solutions – one of which is supporting PCMH home for all Texans

7. Texas PCMH Demonstration Project • Stakeholders meeting convened in Austin June 27,2008 by the Texas ACP, Texas Academy of Family Physicians and Texas Pediatric Society • Meeting chaired by Robert Jackson, MD, Texas Chapter ACP President • More than 30 people attended – major commercial insurers, national ACP, Texas Medical Association, IBM, Health Dialog, State Department of Health Services and others • Presentations on the medical home by Neil Kirschner and Julie Schilz along with local ACP leaders • By the end, there was consensus that enough interest existed to proceed with forming a Steering Committee to explore a pilot project in Texas • Steering Committee consists of the 30 or so people who were at the first meeting along with others who have interest and expertise in the PCMH

8. Texas Patient Centered Medical Home Demonstration Project Texas Chapter ACP Board of Directors- Convening Organization Texas PCMH Demonstration Project Steering Committee Best Practices and Practice Transformation Governance Metrics and Reporting Reimbursement Methodology Patient Advocacy

9. Texas Patient Centered Medical Home Demonstration Project Governance Work Group Charge: • Develop and recommend to the Steering Committee a Steering Committee Charter that addresses the following • Why is this committee being established? • Define the convening authority for this project • Establish the limits on the Committee’s authority and/or scope of work • Outline specific priorities that the Committee must accomplish • Define responsibilities of the leaders and members • Establish expectations for Committee member participation • Establish ground rules that must be adhered to • Define the Committee’s “default” decision-making process

10. Texas Patient Centered Medical Home Demonstration Project Mission Statement Our mission is to promote the Patient Centered Medical Home in Texas. Our goals are: • to improve health outcomes while managing costs and investing in a sustainable infrastructure and • to improve the patient experience while focusing on access, thereby invigorating primary care and enhancing practitioner satisfaction. The project will develop a robust methodology based on best practices to continually evaluate the Medical Home and our patients’ needs. Vision Statement The vision is to lay a foundation which ensures access to a Medical Home for all Texans by the year 2015.

11. Texas Patient Centered Medical Home Demonstration Project Progress to date: • Texas Chapter ACP is convening organization • Adopted Joint Principles; endorsed NCQA certification process • Adopted Mission and Vision statements • Monthly Steering Committee calls and more frequent Work Group calls • Created Weblog to serve as a clearinghouse for meeting minutes, news, articles, calendar • Logo in development • Best Practices Work Group to recommend starting in one region with 3-5 IM and FM practices initially • Plan to include diverse practices (size, demography, payer mix) in pilot • Metrics and Best Practices Work Group meeting jointly to establish elements of project • Will likely include focus on medical home – specialist relationships (appropriate referrals and use of practice guidelines, exchange of information, access, communication) and “handoff” from hospitalists

12. Texas Patient Centered Medical Home Demonstration Project Ongoing challenges: • Study population (adult, children, or both) • Inclusion of public payers • Funding for start-up as well as for practice transformation • Formation of 501 C3 corporation • Increased participation of health care purchasers in project • Texas geography!