After the ACA:
Designing health systems with PCMHs, ACOs and PCTs
Nate Kittle, MS4
Robert Graham Center Visiting Scholar
October 2012
Overview
 Background Information
 Research Question
 Patient Centered Medical Home (PCMH)
 Integrated Systems
 Accountable Care Organizations – ACOs
 Primary Care Trusts (PCTs)
 Putting it all together
 Conclusions
Background Information
 Patient Protection and Affordable Care Act
 Signed into law March 23, 2010.
 Major aim to decrease the number of uninsured Americans
 Mandates
 Subsidies
 Tax Credits
 Upheld by SCOTUS on June 28, 2012.
http://unlikelyvoter.com/2010/03/25/four-polls-on-the-ppaca-democratsstart-out-behind/
PPACA
 Implications of PPACA
 January 1, 2014 = 14 million U.S. residents newly insured!
 By 2021 = Extra 16 million U.S. residents insured
 Grand total = approximately 30 MILLION NEWLY INSURED
lonelyplanetimages.wordpress.com
Who are the 30 Million?
Race
White
Black
Native
American/Pacific
Islander
Asian
Multiracial
Marital status
Married
Single
Language
English
Spanish
Other language
Unknown
Newly
insured
75%
16%
Currently
insured
79%
13%
2%
1%
5%
2%
5%
2%
32%
52%
40%
29%
69%
24%
5%
1%
88%
7%
4%
1%
Who are the 30 Million?
Not in labor force
Newly
insured
27%
Currently
insured
24%
Employed, full time
42%
59%
Employed, part time
17%
15%
12%
15%
Employment status
Unemployed
Education
High school degree or
61%
less
Some college (no
17%
degree)
Associate’s degree
8%
35%
18%
11%
Bachelor’s degree
11%
24%
Graduate degree
3%
13%
Who are the 30 Million?
Excellent
Newly
insured
26%
Currently
insured
37%
Very good
29%
33%
Good
33%
21%
Fair
9%
6%
Poor
3%
2%
Health status
 Compared with the current insured population these patients
will be poorer, older, less likely to have full-time employment, less
likely to have a college degree and more likely to speak a language
other than English. Only a quarter will have previously had health
insurance..
The Impact of 30 million
 The Massachusetts example
 Access and Use of health care improved
 More adults reported visits to doctors and fewer adults reporting going
without needed health care.
 Evidence of strong gains in Preventive care
 Challenges
 Provider Capacity
 “Constraints on provider supply…have ben exacerbated”
 Nearly 15% of adults visited the ED for non-emergency conditions
o 75% because they needed care after hours
o 50% reported not getting an appointment soon enough
Research Question
 What evidence exists for health system reform that may
be able to help curb the possible negative impact of an
extra 30 million insured patients and achieve the Triple
Aim of reform – Better care for individuals; Better health
for the community; and Reduction in the cost of care.
 PCMH
 Integrated Systems (ACOs)
 Primary Care Trusts
Patient Centered Medical Home
 Brief History
 1967: American Academy of Pediatrics introduced the “medical
home”
 2002: The Future of Family Medicine
 Every American should have a Personal Medical Home
 2007: Joint principles of the Patient Centered Medical Home
 American Academy of Family Physicians
 American Academy of Pediatrics
 American College of Physicians
 American Osteopathic Association
PCMH: Joint Principles
 Personal Physician
 Physician Directed Medical





Practice
Whole Person Orientation
Coordinate/Integrated
Care
Quality & Safety
Enhanced Access
Payment Reform
http://thepcmh.org/
PCMH: Realizing the Principles
 Robust investment in Health Information Technology
 eVisits, eCommunitcation, Personal Health Portals, etc.
 Provider payment reform
 Focused on patient outcomes and health system efficiencies
 Team-based education and training of health professionals
 Team of Physician, Case manager, Mental health professional,
Nursing, Patient educator, etc.
http://www.google.com/imgres?um=1&hl=en&rls=com.microsoft:enUS&biw=1024&bih=603&tbm=isch&tbnid=r3-UkndfnFTR5M:&imgrefurl=http://www.aroragroup.biz/&
PCMH: Outcomes
 ED Visits
 Hospital Admissions
 Hospital Length of Stay
 Hospital Re-Admissions
 Total Costs
 Specific Disease Outcomes
http://ondemanddentist.com/268/why-you-should-notgo-to-the-er-for-a-toothache/
PCMH: Outcomes – ED Visits
Initiative
Results
Years of Review
Air Force
14% fewer ED/Urgent care
visits
2009-2011
Florida: Capital Health Plan
37% Lower ED visits
2003-2011
North Carolina:
Community Care
23% lower ED utilization
and costs
2003-2010
Ohio:
34% decrease in ER visits
2008-2010
29% Fewer ED visits
2006-2008
Humana Queen City Physicians
Washington:
Group Health of Washington
PCMH: Outcomes – Hospital Admissions
Initiative
Results
Years of Review
Veterans Health
Administration
27% lower hospitalizations
2007-2009
Pennsylvania:
Geisinger Health PCMH
25% lower hospital
admissions
2005-2010
North Dakota:
BCBS of North Dakota
18% lower inpatient
hospital admission rates
compared to general N.D.
population
2005-2006
Minnesota: HealthPartners
24% fewer hospital
admissions
2004-2009
Alaska: Alaska Native
Medical Center
53% reduction in hospital
admissions
10-year span (not specified)
PCMH: Outcomes – Length of Stay
Initiative
Results
Years of Review
California:
BCBS of California
50% fewer inpatient
stays of 20 days or more
2010
Florida:
Capital Health Plan
40% lower inpatient
hospital days
2003-2011
Minnesota: HealthPartners
30% lower length of stay
2004-2009
Pennsylvania:
Geisinger Health
Reduced hospital length
of stay by half a day
2005-2010
PCMH: Outcomes – Re-Admissions
Initiative
Results
Years of Review
Michigan:
BCBS of Michigan
6% lower 30-day
readmission rates
Minnesota: HealthPartners
40% lower re-admissions
2004-2009
New Jersey:
BCBS of New Jersey
25% fewer hospital
readmissions
2011
Pennsylvania:
Geisinger Health
50% lower readmissions
following discharge
2005-2010
Texas: BCBS of Texas
23% lower readmission
rates
2009
PCMH: Outcomes – Total Costs
Initiative
Results
Years of Review
North Carolina:
Community Care
$60 million in 2003
$161 million in 2006
$103 million in 2007
$204 million in 2008
$295 million in 2009
$382 million 2010
2003-2010
Minnesota: HealthPartners
Overall costs decreased
to 92% of state average
in 2008
2004-2009
Maryland: CareFirst BCBS
Nearly $40 million savings
in 2011
2011
Florida:
Capital Health Plan
18% lower health care
claims costs
2003-2011
Oregon: CareOregon
Medicaid and Dual Eligibles
9% lower PMPM costs
2007-2009
PCMH: Outcomes – Specific Diseases
Initiative
Results
Years of Review
Pennsylvania:
Geisinger Health
Improved quality of care:
• 74% for preventive care
• 22% for coronary artery
care
• 34.5% for diabetes care
2005-2010
Washington:
Regence Blue Shield
14.8% improved patient
reported physical function
and mental function
65% reduced patient
reported missed workdays
2007-2009
Ohio: Humana Queen City
22% decrease in patients
with uncontrolled blood
pressure
2008-2010
Air Force
77% of diabetic patients
2009-2011
had improved glycemic
control at Hill Air Force Base
PCMH: Criticisms
 Variation among programs
 Scalability
 Infrastructure, care teams, etc.
 Large start-up costs
 Lack of long-term results
PCMH: Criticisms
PCMH: Bottom-line
 There are obvious benefits to the PCMH
model but the extreme variability and large
start-up costs cause some
states/organizations to hesitate in its
implementation.
 Is this more than a fad?
Integrated Systems
 Definitions:
 Integration is a set of methods/models on the funding,
administrative, organizational, service delivery and clinical
levels designed to create connectivity alignment and
collaboration between the cure and care sectors.
 The goal: enhance quality of care, consumer satisfaction and
system efficiency
greenologic.co.uk
Integrated Systems - Kaiser
 Poster Child for Integration
 Founded in 1945
 Largest non-profit integrated system in the US
 Consist of Kaiser Foundation Health Plans and Permanente
Medical Groups
 The medical groups are physician owned and function to provide services
for health plan members
worldchiropracticalliance.org
Integrated Systems - Kaiser
 Principles
 Information Continuity – KP HealthConnect
 Care Coordination and Transitions
 Valued role of Primary Care
 Peer Review and Teamwork
 Easy Access to Appropriate Care
 Patient-centered
 Multiple “entry points”
http://67.159.41.164/kp-health-connect.html
Integrated Systems - Kaiser
 Outcomes
 Improving Transitional Care:
 Annual cost savings of $4 million from decreased readmissions (2.4% of
intervention patients vs 14% usual-care) and ED visits (7%-16%
respectively). Satisfaction in the program exceeds 90% of physicians and
95% patients
 With the use of multiple “entry points”
 Northern California members use of ED declined by 1/3 over the course
of 11 years, from rate of 300/1000 adults in 97 to 205/1000 in 08.
Integrated Systems - Kaiser
 Bottom Line
 Rich history of integration that has clearly led to great patient
outcomes, patient satisfaction, physician satisfaction and cost
reduction.
 However, much like PCMH project there needs to be a huge
investment in health IT, you need strong leaders to create a
culture of excellence.
Integrated Systems – ACO
 CMS defines ACO:
 “an organization of health care providers that agrees to
be accountable for the quality, cost and overall care of
Medicare beneficiaries who are enrolled in the
traditional fee-for-service program who are assigned
to the organization.”
 Advocates of this system believe that it will strengthen
the US health care by improving care, controlling
costs, & by holding physicians accountable for results.
Integrated Systems - ACO
 Challenges to Implementing in the US
 Dominance of solo/small-group independent
physician practices
 Voluntary medical staff structure within most hospitals
 Fails to engage physicians in leading the system changes
needed to deliver consistently safe, cost-effective and highquality care
 Dominance of FFS reimbursement
Integrated Systems - ACO
 Medicare’s Physician Group Practice Demonstration
 2000 – Congress asked DHHS to test incentive-based payment
methods for physicians which would aim to encourage care
coordination and an investment in more efficient service
delivery methods.
 CMS contracted with 10 large multispecialty groups with
diverse organizational structures, including free-standing
physician groups, academic faculty practices, integrated delivery
systems and a network of small physician practices.
 Goal is to generate cost savings by reducing avoidable hospital
admissions, readmissions and ED visits while improving quality.
Integrated Systems - ACO
 PGP Demonstration
 Shared Savings:
 Received regular Medicare FFS payments
 Also eligible for an 80% share of Medicare’s savings in practitioners
collectively achieved specified quality and cost targets
policymed.com
Integrated Systems - ACO
 PGP Demonstration Results:
 Mixed at best
 Quality of Care was improved, but little savings were seen
Integrated Systems - ACO
 Bottom Line:
 There is some reason to be concerned. The results were less
then perfect and some analysts believe there may not be enough
of an incentive for organizations to restructure in order to
qualify for ACO Shared Savings.
 There will need to be large investments on health IT, etc. to see
the savings necessary to share in the savings. This may be very
difficult for your average health care system.
Integrated Systems – Other Examples
 Advocate
 Physician – Hospital partnership
 Pay for performance: 10% of allowable billing and based on specialty
specific metrics.
 Patient outreach, reduced hospital LOS, reduced ED use, etc
 In 2010 the partnership distributed $38 million in incentive payments to
3700 physicians.
 Group Health




Consumer-governed health plan
Pre-paid group practice that integrates care and coverage.
Salaried physicians – no fee-for-service pressures
Providers, clinics, hospitals and insurance plans under the same
organization
 Able to make long-term investments in members’ health and manages
resources to get best quality and value.
Integrated Systems – Other Examples
 Geisinger
 Large integrated system in Pennsylvania that offers incentives to
its physicians to improve patient outcomes an cut costs. (20%
total salary)
 Specialists: Quality (40%) Innovation (10%) Legacy (10%), Growth
(15%) and Financial (25%).
 Primary Care: 60% quality measures
 Physicians who receive incentives to achieve all diabetes targets
have better clinical outcomes for MIs, Strokes, retinopathy, and
amputations than patients who receive their care from other
physicians.
Integrated Systems
 Bottom Line:
 Mission to manage the full continuum of care and be
accountable for the overall costs and quality. Can take several
forms: large integrated systems (Kaiser) and Physician-hospital
partnerships (Advocate).
 Performance measurement to evaluate the quality of care and to
prevent potential overuse (FFS) and underuse (Capitation) is a
cornerstone of this model.
 More fully integrated ACOs provide higher quality, more
efficient care than smaller more loosely organized ones.
 Kaiser vs Advocate
Primary Care Trusts
 Brief History
 2000 Launch and
2cuk.co.uk
 303 originally established to:
 Purchase care for local communities from hospitals and other local
providers
 Directly provide services such as community care
 Work with local agencies to tackle health inequalities/improve public
health
 2002 role expansion
 Improve health of the community
 Secure the provision of high-quality services
 Integrate health and social care locally
 2005 – reduced to 152 to match local authorities and strengthen
commissioning
 2010 – Role had expanded to more than 60 separate duties
Primary Care Trusts - Outcomes
 ED Admissions
 Increased by 11.8% from 2004-05 to 2008-09.
 1.35 million extra
 Wide variety when Trusts are compared
 Some saw increases while others saw decreases
 Hypothesize that increase is due to fragmentation of care
ukemergency.co.uk
Primary Care Trusts - Outcomes
 Deficit vs Surplus PCTs
 Deficit: In rural areas – 7 times lower population density
 Surplus: In more socially deprived areas, staff more stressed
 Need to adjust metrics when looking at rural and urban centers to
disperse funds in a more equitable manner.
 Infant and Perinatal Mortality
 70-80% of PCT variability in infant and perinatal mortality can be
explained by combination of deprivation, ethnicity and maternal age
 Differences in PCT spending do not reliably explain differences in
rates of infant and perinatal mortality seen across the country.
Primary Care Trusts - Criticism
 Lack of health IT infrastructure to integrate care
 Lack of strong leadership
 Department of Health priorities limited scope of PCT
effectiveness on local level
 Extreme variability seen between PCTs
alwpctpublichealth.co.uk
Primary Care Trusts – Bottom Line
 Idea to de-centralize commissioning was good in theory but
didn’t necessarily play out over the course of the past decade.
 Too many central NHS priorities got in the way of effective
PCT response to local needs
 Lack of effective leaders trained in commissioning slowed the
process and made for an impatient public
 2013 England abolishing PCTs and are headed to new model
where GP-led organizations commission services.
Taking It a Step Further
 The Medical Neighborhood
 PCMH + Integrated Care System
 Regardless of the organizational structure, an ACO will not succeed
without a strong foundation of high-performing primary care
 Medical home care coordination and care management activities will
enable the ACO to realize cost savings. PCMHs can benefit from ACO
infrastructure and support to help PCMHs meet their functional
requirements
 PCMH is the centerpiece of the medical neighborhood and needs to be
nested within a well-functioning medical neighborhood (ACO) that
ensures everything that needs to happen does indeed happen.
pcpcc.net
The Rhode Island Experiment
 The Medical Neighborhood + PCTs = The Medical
City/County/Township?
 Foundation of primary care (PCMH)
 Integration across all levels of care (primary and secondary)
 Responsive to the local environment by commissioning local
services
 Spain: 2 decades of reform
 Spain ranked 6th among 30 OECD democracies in life expectancy.
 Infant mortality in 09 was among the lowest in the world
 Reduction in the premature deaths from specific conditions:


Circulatory 322.1 to 159.0/100k population
DM 19.8 to 12.5/100k population.
All Models Effect on ED Visits
Model
Change in ED Visits
PCMH (Average of the 5
stated earlier)
Kaiser
27.4% decrease
PCT
50% decrease (300/1000 to
150/1000)
11.8% increase
Conclusions
 There will be 30 million newly insured citizens by 2021
 Need for primary care is well documented
 Continue PCMH programs and report results
 Attempt to identify what REALLY works – decrease variability
 Care integration can increase quality, but does it decrease
costs?
 Health IT, Strong physician leadership
 Lessons from across the pond
 Leadership, only try once, primary care investment works
Thank-you!
Questions/Comments/Future Actions
References (not in Annotated Bibliography)

“Health Insurance Exchanges: Long on options, short on time,” PwC, Oct. 2, (pwc.com/us/en/healthindustries/publications/public-private-health-industry-exchange-models.jhtml)

Long, Sharon “What Is the Evidence on Health Reform in Massachusetts and How Might the Lessons from
Massachusetts Apply to National Health Reform?” Urban Institute Report. June 2010.

“The Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change”
Robert Graham Center Report. November 2007.