Building the Evidence for the
Patient-Centered Medical Home
Eric Schneider, M.D., M.Sc.
Senior Scientist and Director, RAND Boston
Associate Professor, BWH, HMS, HSPH
1
PCMH Assumptions
• Primary care in its
current form faces
extinction
• Changing the
structure of primary
care delivery will
improve process,
outcomes, and costs
of care
• Payment reform is
necessary
2
PCMH Policy:
A Toxic Brew
• High level of desperation among
purchasers
• High level of advocacy by primary care
professional societies
• Uncertainty about model
– Implementation
– Cost of investment
– Effectiveness
3
Research evidence could help,
but…
•
•
•
•
•
Complex interventions
Short time horizons
Small sample sizes
Randomization challenges
Relatively small incentives
4
Need investment and savings
simultaneously
Comparative Public/Private Expenditures on Health - Per Capita
(2004 US$ PPP)
US$ Purchasing Power Parity
Per Capita
7000
6000
5000
3374
4000
3000
956
682
2209
2477
2340
2177
Canada
France
Germany
United Kingdom
703
369
2000
1000
2728
0
public
United States
private
5
What is that state of the evidence?
• What is the medical home intervention?
• Can the medical home…
– change health care delivery?
– reduce the growth of health care costs?
– change the health of the population?
• How readily can the medical home be
implemented?
6
Should we rely on evidence about
parts or on the integrated whole?
7
What, exactly, is the
medical home intervention?
•
•
•
•
•
•
•
Payment scheme
Practice management redesign
Staffing change
Clinician behavior modification program
Patient behavior modification program
Communications project
Health information technology project
8
Is it a bold stroke or an
incremental change?
• Does the Ptolemaic
pecking order remain
in place?
–
–
–
–
–
–
Hospital
Specialist physician
Generalist physician
Ancillary professionals
Staff
Patient
9
Is it standardized?
10
Or a local, custom build?
11
NCQA PPC-PCMH Scoring
Standard 1: Access and Communication
A.
Has written standards for patient access and patient
communication**
B.
Uses data to show it meets its standards for patient
access and communication**
Pt
4
5
9
Standard 2: Patient Tracking and Registry Functions
A. Uses data system for basic patient information
(mostly non-clinical data)
B. Has clinical data system with clinical data in
searchable data fields
C. Uses the clinical data system
D. Uses paper or electronic-based charting tools to organize
clinical information**
E.
Uses data to identify important diagnoses and conditions
in practice**
F.
Generates lists of patients and reminds patients and
clinicians of services needed (population
management)
Pt
Standard 3: Care Management
A.
Adopts and implements evidence-based guidelines for
three conditions **
B. Generates reminders about preventive services for
clinicians
C. Uses non-physician staff to manage patient care
D. Conducts care management, including care plans,
assessing progress, addressing barriers
E.
Coordinates care//follow-up for patients who receive
care in inpatient and outpatient facilities
Pt
2
Standard 5: Electronic Prescribing
s A. Uses electronic system to write prescriptions
B. Has electronic prescription writer with safety
checks
C. Has electronic prescription writer with cost
checks
Pts
3
3
Standard 6: Test Tracking
Tracks tests and identifies abnormal results
s A.
systematically**
B. Uses electronic systems to order and retrieve
tests and flag duplicate tests
Pts
7
Standard 7: Referral Tracking
A.
Tracks referrals using paper-based or electronic
system**
Pts
4
3
3
6
4
3
21
3
4
3
5
8
6
13
4
Standard 8: Performance Reporting and Improvement
A.
Measures clinical and/or service performance by
physician or across the practice**
B. Survey of patients’ care experience
C. Reports performance across the practice or by
s
physician **
D. Sets goals and takes action to improve
performance
E.
Produces reports using standardized measures
F.
Transmits reports with standardized measures
electronically to external entities
Pts
3
3
3
3
2
1
15
5
Standard 9: Advanced Electronic Communications
A. Availability of Interactive Website
B. Electronic Patient Identification
C. Electronic Care Management Support
20
Standard 4: Patient Self-Management Support
A. Assesses language preference and other
communication barriers
B.
Actively supports patient self-management**
2
Pt
Pts
1
2
1
s
2
4
6
4
**Must Pass Elements
12
Evaluated Models
1. The pediatric medical home
2. Community Care of North Carolina
(CCNC)
3. National Demonstration Project
(TransforMED project)
13
Can the medical home change
health care delivery?
•
•
•
•
•
COSTS
Clinical care process (measurable)
Access
Patient experience of care
Staff work-life satisfaction
14
1. Pediatric Medical Home
• Systematic review
– 33 published papers describing 30 studies
– 9 studies included comparison groups
• Results
– Most address children with special health care needs
– Variety of implementations (none complete)
– Generally positive associations between medical
home and
•
•
•
•
better health status
timeliness of care
family centeredness
improved family functioning
Homer CJ et al., Pediatrics, 2008
15
2. Community Care of North Carolina
(1998-2002)
• Goal of CCNC
– to develop local networks of primary care providers to
coordinate prevention, treatment, referral and
institutional services for Medicaid beneficiaries
• Chronic disease focus (asthma, DM, etc.)
• Structure
– 12 Networks (1 statewide and 11 local)
– 246 Providers/practices
– 252,190 Medicaid beneficiaries
http://www.communitycarenc.com/
16
Cost savings
• Estimated Medicaid savings over 3 years for
beneficiaries with asthma or diabetes in CCNC
program (compared to ACCESS program after
age adjustment):
– Asthma: approx $3.3 million
– Diabetes care approx $2.1 million
• if all eligible persons in North Carolina were
treated in CCNC networks (rather than ACCESS
program) projected savings (on average) would
have been $5.9 million in 2002
17
Utilization reduction
18
Changes in process of care
were modest at best
19
CCNC Update 2007
• Savings projected at between $135 - $149
million over what would have been spent
without any effort to contain costs
20
3. National Demonstration Project
• 36 practices
– selected from 337 motivated applicants
• Randomized to facilitated vs. self-directed
change
– Facilitation included coaching
• Two-year implementation period
– Ended June 2008
Nutting et al, Annals of Family Medicine, 2009
21
National Demonstration Project:
Initial Lessons Learned
• Becoming a PCMH requires transformation
• Technology needed for the PCMH is not ‘plugand-play’
• Transformation to the PCMH requires personal
transformation of physicians
• Change fatigue is a serious concern even within
capable and highly motivated practices
• Transformation to a PCMH is a developmental
process
• Transformation is a local process
Nutting et al, Annals of Family Medicine, 2009
22
Readiness for the PCMH?
Evidence from Massachusetts
Assistance and reminders
Specially-trained staff assist patient self-management
Shared system to contact patients for clinical preventive
services
Paper reminders
(% of sites)
57
53
44
Culture of quality
Feedback on clinical quality
Feedback on patient experience ratings
New initiatives on clinical quality
New initiatives on patient experience ratings
Frequent meetings to discuss quality
Practice has leader for clinical quality
88
66
73
47
43
58
Friedberg MF et al, Journal of General Internal Medicine, 2009
23
Prevalence of structural capabilities
Access
≥1 clinician provides care in language other than English
On-site language interpreters
Open for regular care on weekends
(% of sites)
57
32
24
Electronic health records
Frequent use*
75
Specific functionalities
Radiology results
Lab results
Specialist notes
Medication list
Problem list
E-reminders
Frequently-used, multi-functional EHR†
*Computer used “usually” or “always” during patient visits.
†EHR is frequently used and has all listed functionalities.
88
88
63
63
53
44
33
24
State of the Evidence:
“Known unknowns”
• What is the medical home intervention?
– striving toward the NCQA PPC-PCMH standard
• Can the medical home…
– change health care delivery?
• Probably true for selected settings and populations
– reduce the growth of health care costs?
• Unknown
– change the health of the population?
• Unknown
• How readily can the medical home be
implemented?
– unknown
25
Will evidence influence policy?
26
Commonwealth Fund
PCMH Evaluators’ Collaborative
• Many evaluation projects across U.S.
• Attempting to rigorously measure…
–
–
–
–
–
financing, costs, and savings
degree of implementation of PCMH components
changes in patient experience of care
staff work-life satisfaction
changes in clinical care processes
• Workgroups striving to standardize
measurement despite heterogeneity of
demonstrations
27
Transformation in Parallel:
A Chicago Perspective
28