PCMH-How Does a Practice Get There?

The Last blog introduced the Patient Centered Medical Home (PCMH) construct as a means of attacking the Health Care Crisis by improving both personal and population health and lowering cost thus creating value for health care stakeholders.

It was also mentioned that the transformative process require investments, both financial and intellectual. There is a roadmap to becoming a PCMH. The National Committee for Quality Improvement (NCQA) has established a Recognition program which outlines standards which must be met to gain Recognition at 3 distinct Levels. The Joint Commission (TJC) has its own certifying process. Thus far over 19,000 PCPs nationwide have gained NCQA Recognition, most of which at Level 3, the highest possible Level. The Standards are available on the NCQA web site (http://www.ncqa.org/tabid/631/default.aspx) . The transformation process involves work flow alterations, improved access, policies and procedures and appropriate use of Health Information Technology (HIT).

It is the acquisition of HIT which represents the major financial investment necessary to become a PCMH. It is difficult, if not impossible, to improve quality without being able to measure it and then reassess after initiating quality improvement processes. In order to do this efficiently, an Electronic Medical Record (EMR) or Clinical Registry is necessary. The purchase of EMRs can be very expensive. CMS has recognized this problem and has provided incentives for practices to acquire HIT. A provider who acquires, implements and brings to “Meaningful Use” (MU) a government certified EMR is eligible to receive a $44,000 incentive payment. Interestingly, the MU criteria closely mirror the NCQA Standards for PCMH Recognition. A greater incentive is available to providers who see a minimal number of Medicaid patients.

Help is available to practices wishing to become PCMHs. The American College of Physicians (ACP) has created a software tool called the Medical Home Builder© which allows practices to self assess their readiness to become a PCMH. The tool also provides resources which will assist practices in meeting NCQA Standards. There are also consulting programs which provide guidance to committed practices. Recently, the Physicians Foundation funded a program to deliver such consultation to 19 practices (105 physicians) in Connecticut. Most practices were awarded Level 3 NCQA Recognition after completion of the program.

Becoming a PCMH is imminently possible; over 19,000 PCPs have already done so. It is the right thing to do. The solution the Health Care Crisis depends upon it.

The CSMS-IPA provides primary care practices to both the ACP Medical Home Builder as well as programs for the development of Patient Centered Medical Homes. Contact the IPA for more information on these programs at info@csms-ipa.com or find additional resources at the CSMS-IPA web site at www.csms-ipa.com.

Ken Sacks, M.D., Medical Director CSMS-IPA

 

Health Care Crisis Solution #1- The Patient Centered Medical Home (PCMH)

Previous Blogs have dealt with defining the Health Care Crisis and its causes. Let’s not discuss problems without identifying potential solutions. One potential solution is the widespread transformation of Primary Care Practices toward Patient Centered Care delivered by a PCMH. The concept of a PCMH is actually quite old; the American Academy of Pediatrics first proposed this concept in 1967. Of late other Medical Societies (American College of Physicians, American Academy of Family Practice and the American Osteopathic Association) have both embraced and codified the concept with 7 agreed upon Principles. In fact, the National Committee for Quality Assurance (NCQA) has established a formal Recognition program at 3 distinct levels of PCMH. The Joint Commission (TJC) has a similar Certification Program. A grassroots organization, the Patient Centered Primary Care Collaborative (PCPCC) has been developed with support from many organizations, especially major employer groups. The mission for all these groups is to transform Primary Care from is current form to a construct better able to deliver high quality cost effective health care- the PCMH.

Recognizing the issues of access, redundancy, patient responsibility, coordination of care and wellness, a PCMH seeks to provide a complete and comprehensive care experience which builds upon a trusted Physician/Patient relationship and stresses wellness and prevention in addition to acute care. The Patient is at the center of the care paradigm and is supported by a team of providers led by the Primary Care Physician (PCP). Utilizing team members functioning at the highest level of licensure and supported by Health Information Technology (HIT), the PCMH can decrease preventable, costly admissions to hospital and Emergency Rooms, identify gaps in care of chronic conditions, provide evidenced based care, coordinate care with other providers and engage the Patient in their own wellness. In doing so, the PCMH can improve quality and access and reduce the costs which are responsible for the current crisis. But will it work?

There is accumulating evidence that it the PCMH can and does result in better quality care at reduced cost. Countries with a robust Primary Care workforce using modern HIT have better outcomes at far less cost that does the United States. In Sweden, this has resulted in closing many hospitals due to the dramatic decrease in avoidable admissions. Here at home, communities with a strong PCP presence accomplish the same results. PCMH pilots and demonstrations uniformly show quality improvement and frequently produce cost savings. Given sufficient time, the downstream effects of quality improvement and enhanced access will lower the cost of health care.

The transformation of an existing PCP Practice to a PCMH is not an easy or quick process. It involves a cultural and structural change in the way PCPs have traditionally provided care. It also requires the engagement of the patient as an active participant in their own care and wellness. Accomplishing this requires resources, both intellectual and financial, commitment and time. Without transforming Primary Care the remainder of the reform plan can not be put in place. Take some time to do an online search for PCMH?. The details are far beyond the scope of this blog.

Ken Sacks, M.D., Medical Director CSMS-IPA

Go to http://www.csms-ipa.com/ for more information

What Went Wrong

If you have been reading the earlier blogs perhaps you have come to realize that the health care delivery model in this country is not sustainable. Our population health statistics are poor, receipt of quality care is at best a 50/50 proposition and finally the cost of healthcare is, without a doubt, untenable. What are the root issues which have resulted in this crisis? My intention is not to blame any one stakeholder, but rather to highlight areas which have contributed to the current situation. The following are but a few of the factors which have influenced the United States health care paradigm

Physician Payment Methodology: For most physicians and hospitals, compensation is volume driven. The more that is done, the greater the remuneration provided. Outcomes and quality have not generally figured in to compensation. Number of visits, number of procedures and number of tests ordered determine how much a physician or a facility gets paid. Understanding this simple principle allows one to appreciate the geographic disparities in care which have been pointed out by the Dartmouth Atlas and others. This methodology is not universal. There are entities which integrate hospital care and salaried physicians and achieve better quality and reduced cost. Examples are the Cleveland Clinic, the Geisinger Clinic and the Kaiser-Permanente system. There are attempts to control this activity at the hospital level by instituting per diem rates or, as CMS has done, a DRG bundled payment. There is also legislation (Stark) which forbids a physician from referring to an entity in which that physician has a financial interest. This law has many loopholes and safe harbors. The United States is a free and capitalistic society; stakeholders are simply functioning within the existing paradigm to best advantage themselves. The business of the US is BUSINESS.

Patient Expectations and Responsibilities: In an environment where 85% of US citizens have health care coverage of some form, patients have come to expect that better care somehow means more care. Patients demand unnecessary testing, treatment and consultations which in no way provides them with better care. It simply incurs cost. Physicians, fearing that they might lose a patient, tend to comply with these demands. The physician rationalizes that the costs of unnecessary care are covered by their patients’ insurance. In truth the cost is ultimately passed on to the insurance purchaser. In addition, patients are all too likely to fail in the creation of a healthy life style. The epidemic levels of obesity are a case in point. This system has resulted in a medically illiterate populace, demanding more care and refusing to take responsibility for their wellness. Cost shifting in the form of increased co pays and deductibles has had some impact but run the risk of patients not receiving needed preventive care nor, when illness strikes, the right care at the right time.

Communication and Coordination: American medicine offers a plethora of highly trained medical specialists. These physicians have the expertise to provide state of the art care within their specialty. That is the positive. The negative is that the norm has become care provided in specialty silos with little or no communication and coordination among providers. This can lead to redundancy and medication errors which impact cost and quality. Enhanced communication and better coordination of care are necessary to improve patient safety and eliminate waste from the health care system.
For Profit Insurance companies: In true American entrepreneurial fashion, a massive health insurance industry has evolved over the last 4 decades. For the most part these are for profit publically held companies which are beholden to the shareholders. To achieve a profit these organizations must be able to cover their administrative costs, pay for all covered health care services and still have money left over. This can be accomplished by managing care better, reducing overhead and increasing revenues. In the last decade health care premiums have increased over 70%. A recent New York Times article addressed the record profits of major health insurers; these same insurers are requesting double digit increases in premiums. More needs to be done to manage care, not cost. Many of these issues are addressed in the Affordable Care Act. A public, not for profit insurance option is not in the legislation.

There are other components to our health care conundrum which can be mentioned but not elaborated upon. Tort reform to address the cost of “defensive medical practices” is one of them. Politics, as evidenced during the debates which lead to passage of the Affordable Care Act and continue with Tea Party congressional delegates, also needs to be mentioned. The more one thinks about it the more potential causes of our health care crisis emerge. We have a complicated health care system with multiple stakeholders whose interests are frequently not aligned. Solutions must be multifaceted if the health care crisis is to be improved

Ken Sacks, M.D., Medical Director CSMS-IPA

Health Care Access

As one reads about the objectives that Health Care Reform means to address, one encounters terms such as “Triple Aim” and, in the recent CMS Medicare Accountable Care Organization Proposed Rule, “3 Part Aim”. These refer to the 3 components necessary to maintain a successful Health Care delivery system- Sustainable Cost, Improved Quality and Better Access. Some believe that only 2 of these attributes can be achieved; the 3^rd must be sacrificed to accomplish the other 2. Health Care planners disagree and look toward changes necessary to accomplish the “Triple Aim”. Prior postings have dealt with Cost and Quality. This discussion regards Access.

Access is a function of multiple factors. Some of these include:

1. Insurance Status
2. Health Care Work Force
3. Population Demographics

Let’s consider each of these.

 As previously stated, the United States is the only industrialized country which does not guarantee access to health care as a right of citizenship. Approximately 85% of US citizens do have some sort of insurance coverage; 50% of private insurance is provided by employers. More and more employers are “shifting” the cost of health care to their employees in order to continue to provide some insurance benefits. The cost shifting creates a potential barrier for health care access based on affordability. Primary Care Physicians are reporting significant drops in the volume of patient visits, presumably secondary to cost considerations. 28% of the population is covered by government programs, namely Medicare, Medicaid and various children’s programs. Medicare is the largest of these programs and does not fully cover all health care related costs. Seniors who can not afford Medicare “gap” or “wrap” policies frequently fail to get necessary care because of cost. Over 50 million people either can not afford or choose not to purchase insurance. These individuals typically delay care, resulting in preventable illness and more costly interventions. Many such individuals end up seeking acute care in Emergency Rooms rather than arranging a consultation with a PCP. How long did you or a family member have to wait to be seen in an ER for a true emergency?

Even for those with adequate health care insurance, access to their Personal Physician or Primary Care Physician (PCP) may prove to be difficult. The ranks of the PCP are being depleted by early retirement and a failure to replenish the supply from medical training programs. Recent statistics suggest that only 4% of medical school graduates consider a career in primary care. Existing practices have been slow to adopt the tools and work flow changes necessary to care for their patients in an efficient way. The reasons for early retirement, lack of student interest and failure to invest in staff and technology can be simply explained by the fact that PCPs are not compensated adequately. Many communities have far more specialists than PCPs. Patients may have an easier time accessing care from these physicians, but because the care is specialty focused they may not receive recommended preventive services and their care may be less coordinated than had a PCP been involved.

Demographics also play a role in access to health care. The “Baby Boomer” generation is about to hit Medicare in a huge way. It is estimated that over 7,000 baby boomers become Medicare eligible EVERY DAY! Millions will shift to Medicare in the coming decade and, as they age, demand more and more access to care. The provision of care for these individuals will further strain an already burdened access system.

Collectively we have got to figure out a road map to creating Health Care value and access. That road map will have to include Health Information Technology adoption, work flow changes, payment innovation and patient engagement. Keep watching.

 

Ken Sacks, M.D., Medical Director CSMS-IPA

 

Value in Health Care

How does one define and measure “value” in the US Health care system? Perhaps the easiest and best formula which can be used is: Value equals Quality divided by Cost (V = Q/C). As the last posting tried to illustrate, cost of Health Care in the United States is substantially higher than that found in other industrialized nations. Therefore, assuming that the Quality of care is the same from nation to nation, the Value of the Health Care provided to US citizens is less than is found in other countries. What makes the Value equation even more problematic is that the Quality of care does not conform to standards set by other nations. Care Quality here is worse, thus creating and even lower Value score. This is coupled with the fact that the United States is the only industrialized country which does not offer Universal Health Care to its citizens.

The World Health Organization (WHO) ranks the US 37th in the world. Although we rank very highly in areas such as Responsiveness and Cancer outcomes, other areas are less satisfactory. In Life Expectancy we rank 42nd, Infant Mortality 41st and we are 72nd in the category of general health of the population. The Commonwealth Fund has performed similar comparative studies. According to them the United States is dead last when compared to similar countries. The Commonwealth Fund has reported that US citizens are far less likely to have regular and preventive care visits; only 50% receive recommended preventive care. Furthermore, only 70% of acute care meets evidence based standards (30% of acute care is contraindicated) while 60% of chronic care meets recommended standards and 20% is actually considered contraindicated. Overall, the Commonwealth Fund gives the United States a 71/100 score for Quality. This information is consistent with the Rand Report which also found that recommended care is provided only 55% of the time.

Patient Safety is also a component of Quality. In their “To Err is Human” paper, the Institute of Medicine reported that between 44,000 and 98,000 deaths occur annually as a result of medical errors. Using the lower figure, this translates to more deaths due to error than are caused by either motor vehicle accidents or breast cancer.

Considering our high cost of Health Care, these Quality statistics drive the Value score even lower. To create real Value in Health Care, solutions to both high Cost and low Quality need to be developed. Keep watching.

 

Ken Sacks, M.D., Medical Director CSMS-IPA

Healthcare Reform

Regardless of how you may feel about “Obama Care” and other Healthcare reform initiatives put forward by federal and state governments, it is critical that all stakeholders understand that the current Healthcare delivery system in the United States represents an unsustainable model. It is unsustainable for economic reasons, for sure, but also unsustainable from a quality and access perspective. This message will focus on the economic imperative driving the call for Healthcare reform.

Make no mistake, when it comes to scientific advancements and innovative treatments, the United States leads the world. Unfortunately this does not translate to providing quality affordable care for US citizens. On a per capita basis, the United States spends approximately twice that of comparable countries. Even if this resulted in better outcomes, which it does not; the cost would remain the driver for Healthcare reform. Consider the following sober statistics:

1. In 2007 the United States spent 2.2 trillion dollars on Healthcare. This represented 17% of the Gross Domestic Product (GDP). In the 1960, Healthcare consumed 5% of the GDP; in 1990 the figure had risen to 11.9%  
2. Healthcare Insurance premiums have risen 73% since 1999, while wages increased only 15% over the same timeframe.  
3. The Medicare Reserve is projected to be exhausted by 2017. This is not so far away. 

What does this mean for Healthcare Stakeholders? For recipients of Healthcare, the patients, it means that purchasing Healthcare Insurance will become completely unaffordable. Patients will be left with very high deductible plans or no insurance at all. Both contribute to a real risk of bankruptcy, which is already a considerable problem. Employers, in order to remain competitive in the delivery of goods and services, will need to decide to curtail Healthcare Benefits, reduce wages or reduce employees. None of these choices is good for the economy. The federal government is also confronted with hard choices. In order to maintain the Medicare safety net, the government will need to increase revenue (read as increase taxes) or borrow even more money. Increasing our national debt is not in anyone’s best interest.

If all can agree that the economies at play demand that the present system of Healthcare delivery be reformed, then we can begin the dialogue as to the root causes of the current dysfunction and how to best address the problems. These subjects will be addressed in future messages.

Ken Sacks, M.D., Medical Director CSMS-IPA