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://18.104.22.168/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.