HOME SWEET MEDICAL HOME Brian T. Engel, MD Pediatrician, Northpointe Pediatrics Chairman, St John Medical Group PGIP
Introduction • Patient-Centered Medical Home (PCMH) Defined • PCMH-The Past • PCMH-The Present and The Future • PCMH Success • Northpointe Pediatrics PCMH • Challenges • Summary
American Academy of Pediatrics (AAP), 1967 • A medical home is primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective
Home Sweet Medical Home, 2009 • Your medical home at Northpointe Pediatrics is a place that can take care of all your children’s health care needs from “cradle to college”. However, it is more than a place; it is a continuous relationship with your child’s pediatrician and our team of medical professionals that puts the patient at the center of care.
PCMH-The Past • Pre-1980: Fee-For-Service Model • High costs, trust of physicians and “the system” is high (blind faith?) • 1980’s and 1990’s: Managed Care Model and Gatekeepers • Lower costs, but distrust of physicians and “the system” soars (rationing care?) • Early 2000’s: Hybrid Model (Modified FFS/Managed Care) • Costs escalating, distrust rampant (Gatekeeper is dying breed)
PCMH-The Present and The Future • “Back to the future” • Re-birth of the PCMH (Designations by NCQA 2008 and BCBSM 2009) • Out with the bad: • The Gatekeeper is dead and buried • In with the good: • Re-establishing respect and trust between patients, physicians and payers • Primary care physicians (PCPs) are patient advocates that can help the patient and their families navigate the heath care system
PCMH Success • We all must change our way of thinking… • Wheezing ≠ Allergist or ER visit • Zits ≠ Dermatologist visit • Sprained ankle ≠ Orthopedic or ER visit • Obesity ≠ Gastric Bypass • Success depends on the mutual respect, trust and cooperation between the patient, the PCP (and his/her team), the specialists and the payers
Northpointe Pediatrics PCMH • Childhood Obesity • The problem: • 75% of health care dollars ($1.5 trillion) are spent on chronic conditions • In 1998 $74 billion was spent on obesity-related conditions and in 2008 $147 billion was spent • 33-35% of kids are overweight (BMI>85%), 17-20% of kids are obese (BMI>95%) • Our solution: • Chronic Care Travel Team (with Medical Network One) was established in 2006 with a focus on Individual Care Management • The CCTT is a physician-lead team which includes an RN, Dietician, Exercise Specialist and a Wellness Counselor
Northpointe Pediatrics PCMH • Asthma Registry • The problem: • PCPs (like us) were doing a good job, but not a great job, of managing chronic conditions like asthma • Our solution: • An Asthma Registry: an electronic database to monitor and manage ALL our asthmatic patients which is available at the point-of-care; the registry incorporates evidence-based guidelines
Northpointe Pediatrics PCMH • Physician Dispensing • The problem: • Our patients would at times leave our office and either be non-compliant (they didn’t fill the medication prescribed) or experience medication errors • Our solution: • In 2006 we started dispensing medications at the point-of-care in a our office; since then, we have seen improved patient compliance, reduced medication errors, lower costs for the patient and the payers (our GUR is 87%) and improved patient satisfaction
Northpointe Pediatrics PCMH • Patient Portal • The problem: • Poor communication between physicians and their patients • Patients need a secure, confidential and portable Patient Health Record (PHR) • Our solution: • Our Patient Portal, RelayHealth, allows online communication between our office and our patients • Patients and their family members have free access to a PHR • Patients can request online prescription refills and renewals, specialist referrals, appointments, and web visits
Northpointe Pediatrics PCMH • Performance Reporting • The problem: • Insurers data about key chronic conditions and preventative care showed “gaps in care”; most of the “gaps” were opportunities to improve care, some of the “gaps” were from poor data collection • Our solution: • Our registries for chronic conditions (like asthma) and preventative care (MCIR, BCN’s Health-e Blue, HAP’s Member Health Manager) help us implement care delivery systems that outreach to patients and close “gaps in care” • The outcome: Patients benefit (care is better and proactive rather than reactive), physicians benefit (P4P dollars and better work flows for improved patient care), payers benefit (healthier patients and lower costs)
Challenges • Childhood Obesity • Obesity is still not a billable code • BCBSM/BCN are the only insurers that recognize the CCTT with payments (T-codes) • Asthma Registry • Some patients are suspicious of “specialist” care by their PCP • Some specialists feel threatened by a loss of business, but shouldn’t be • Physician Dispensing • Although physician dispensers are contracted participants of the Good Neighbor Pharmacy Provider Network (GNPPN), the entity is still not universally recognized by insurers
Challenges • Patient Portal • Even though we deal with the “techie” generation, only 20% of our 12,000 patients communicate with us online • Are Obama’s “meaningful use” stimulus dollars for EMR attainable? • Performance Reporting • An inherent conflict exists: while physicians are promoting the PCMH concept, some insurers are still “rewarding” patient care outside the PCMH (no ER co-pays, Urgent Care check-ups, Minute Clinic visits)
Summary • The PCMH is the answer to our health care woes in primary care • We can achieve quality patient-centered medical care in a cost-effective fashion • To do so, we must go “back to the future” and re-establish a trusting and cooperative relationship between patients, physicians and payers • Change is hard, but change is good!