1 / 47

Randy Cook, MPH , FACMPE President/CEO

B uilding Integrated Communities of Care: PCMHs & ACOs. Marjie Harbrecht, MD CEO. Randy Cook, MPH , FACMPE President/CEO. Learning Objectives. Discover the high-leverage changes of PCMH’s to get results Describe how PCMH’s can serve as the foundation of ACOs

Télécharger la présentation

Randy Cook, MPH , FACMPE President/CEO

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.


Presentation Transcript

  1. Building Integrated Communities of Care: PCMHs & ACOs Marjie Harbrecht, MD CEO Randy Cook,MPH, FACMPE President/CEO

  2. Learning Objectives • Discover the high-leverage changes of PCMH’s to get results • Describe how PCMH’s can serve as the foundation of ACOs • Identify reimbursement payment programs that emphasize for “value” rather than “volume”

  3. U.S. Health Care • Great Skills • Great Science • Poor Integration / Coordination • Fragmented - Silos • Misaligned Incentives • Culture

  4. What Do People Really Want? • Trusting Relationship with Care Team • “I can reach someone who knows me, knows my history, can advise me and cares about my issues” • Service • “I can get care or contact with someone when I feel I need to, without having to always come in” • “Less waiting in general” – during visits, for test results, for referrals, for refills, etc. • Reliable, Coordinated Care • “My care is coordinated” – between providers, hospital/ER, home health, behavioral health, etc

  5. What Do We Want? • Trusting Relationship with Our Patients, Colleagues and Staff • Job Satisfaction • Provide the best, most efficient care possible • Make a difference in our patient’s lives • Work-Life Balance

  6. The Triple Aim By The Institute for Healthcare Improvement Population Health Experience of Care Per Capita Cost

  7. Déjà vu… All Over Again? • Tremendous consolidation of market • What’s different from Managed Care days? • Practice and community redesign • No-one taught us how before • Gatekeeper to Gateway • Better tools (Technology) to coordinate care • Patient sophistication and engagement • Aligned incentives for ALL to work together • Quality – Affordability - Satisfaction • Realization that no one can do this alone!

  8. Ideal State • Shared “community” vision • Shared data – timely, actionable, in usable format • Available at point of care • List of those needing services - for outreach • Aggregated across community to identify target areas for improvement and monitor progress • Shared Care Plans • Everyone that touches patient on the same page…including the patient/family

  9. Patient-Centered Medical Home (PCMH) An approach to providing high-quality, safe, continuous, coordinated, comprehensive care, with a partnership between patients and their personal health care team… “The kind of care you’d want your Mom to have!”

  10. BUILDING A SOLID FOUNDATIONFundamentals for Transforming Leadership & Team Based Care Patient Engagement & Access Patient Centered Medical Homes Care Mgmt, Coordination & Communication Technology, Data & Outcomes Reporting Evidence-Based Medicine and Population Management

  11. New payment modelsAllow a new way of thinking! Panel Management Transition from FFS “Treadmill Medicine” to coordinated planned management of entire panel, with extra care for those who need it Redefine “VISITS” – enhance access and convenience Help patients set goals – use teams to support them in achieving those goals 12

  12. Patient Centered Planned Care Before, During, and After Visit Develop Customized Care Plan Shared-decision making Prevention, Chronic Conditions, Acute Care Issues Warm Handover to Care Coordinator/Care Manager Track tests/referrals, coordinate with medical neighborhood, monitor registry/EMR Engage patients, help them overcome barriers Concentrate on high risk/high need patients 13

  13. Prioritizing Care Management & Care Coordination Multiple Chronic Conditions & Complex Patients

  14. A Medical Home Without An Integrated Medical Neighborhood Is Just An Island

  15. Integrated Community Care Provided Courtesy of Premier Healthcare Alliance

  16. ACO Vs. PCMH • A PCMH is a care delivery system • Primary Care (usually) • Help patients navigate system • Foundation for ACO • An Accountable Care Organization (ACO) • A business structure under which multiple providers (i.e., primary care, specialists, hospitals, etc) agree to care for a particular population of patients and be accountable for quality, cost, experience of care.


  18. Coordination Gaps With and Without Medical Homes Percent* • Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care. • Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

  19. Building The Medical Neighborhood Specialists (PCMH-N) • ACP Framework and Compacts; NCQA Hospitals • Identification, Notification, Communication Mental/Behavioral Health • Overcoming HIPAA, Carve Outs Shared Resources – Expanded “TEAM” • Complex Care Managers, Clinical Pharmacists, Social Workers, Educators, Mental Health Providers, Home Health… Community Resources • Awareness and Connections

  20. Reasons Why This Ain’t Been Easy • The typical primary care physician has 229 other physicians working in 117 practices with which care must be coordinated. Pham et. al Ann Int Med. 2009 • In the Medicare population, the average beneficiary sees seven different physicians and fills upwards of 20 prescriptions per year Partnership for Solutions, Johns Hopkins Univ. 2002

  21. “Culture eats strategy for lunch…over and over again.” Tactics Versus Culture


  23. When Teams Don’t Work Well…

  24. U.S. Men's Basketball Falls Flat on World StageBy David DuPree, USA TODAYAugust 15, 2004 ATHENS- “This is the Olympics, and the U.S. men's basketball team was rocked, shocked, humiliated and exposed on sports biggest stage Sunday as Puerto Rico, a Commonwealth of 4 million residents, pulled off the upset of all Olympic upsets with a 92-73 drubbing of the Americans.” Most SKILLED players in the world - What went wrong?? GREAT PLAYERS vs. GREAT TEAM

  25. Individual Choice VS Team Efficiency

  26. REALLY??

  27. When Teams Work Well…

  28. First Step: Create Your Shared Vision

  29. Mutual respect of what each brings to the table Recognition of the value of role differentiation Acknowledgement of a flawed system Clarifying misconceptions Striving for “professionalism” Better communication, consideration, cooperation Always return to: Patient-Centered Care Identify Pain Points – Work Toward Solutions and Common Goals

  30. Investment Required to Reduce CHAOS and Build Solid Infrastructure IT’S ALL ABOUT RELATIONSHIPS!!

  31. With OurPATIENTS! With Our TEAMS With Our NEIGHBORS Building Accountability to Each Other and Our Communities

  32. The Market is Changing • Opposite incentives • The problem is the transition Fee-for-service (FFS) is in decline Fee-for-quality (FFQ) is increasing

  33. The Market is Changing

  34. The Market is Changing

  35. ACOs – Getting Paid For Value ACOs are one, among others, method of getting paid for value Generate savings and Medicare returns ½ 10 PCPs could earn $6 + million in shared savings Lots of types of ACOs but all are based on PCPs A PCMH has a leg up on the opportunity to create savings

  36. Getting Paid As A PCMH • Getting paid is principle # 8 • A PCMHcreating its own ACO is one way • Other methods • Pay for performance (P4P) • Capitation (Not PCP capitation) • Gain sharing agreements • Fee-For-Service Add-ons

  37. Pay for Performance - Measures • Cost / utilization thresholds • ER visit rates • Readmission rates • Cost of targeted types of care • Generic scripts percent • Quality measures (Process) • % of Diabetic patients whose HbA1c has been tested • % of CHF patients whose LDL has been tested • % of Hypertension patients whose BP has been checked • Quality measures (Outcome) • % of Diabetic patients whose HbA1c is under control • % of CHF patients on ACE/ARB therapy • % of Hypertension patients with BP <140/90

  38. Pay For Performance - Payment • Bonuses earned for each measure achieved • Bonuses paid as a percent of fees paid • Future fee schedules set based on performance • More complex measures • Groups of providers • Measures dependent on actions of multiple providers

  39. Capitation • Fixed payment based on population, NOT the services that are required • PCP capitation is contrary to PCMHphilosophy • Underwriting risk and operational risk • Adverse selection • Responsibility for payments to providers • Pros: • All savings accrue to the capitated provider • Price per unit is available as a cost savings variable • Cons: • New critical requirements, before you manage cost • The risk of negatively influencing quality

  40. Gain / Loss Sharing • A budget is agreed and actual expenses are compared • Savings (and maybe losses) are shared • Underwriting risk remains, but not operational risk • Pros: • Plan administers payments and pools risk • Gain side only is possible & losses are shared • Cons: • Price per unit is not available as a variable • Savings must be shared

  41. Fee-For-Service Add-ons • Case management fees • Fixed PMPM payment for PCMH activity, over Fee-for-Service • Case management service • Plan provides a case manager to collect data and perform selected functions

  42. Summary • ACO = Payment model (Government or Commercial) • PCMH = Delivery system, regardless of payment model • PCMH built around 8 principles • PCMH provides value to the market • Several ways PCMH can get paid

  43. QUESTIONS? www.AmpliPHYps.com www.HealthTeamWorks.org

More Related