The what and why of Patient-Centered Medical Home – ADC

Thank you very much for coming to our clinic today It is my privilege to be here to help explain some of the changes in the health care system Let me explain why we need a patient-centered medical home before I explain what it is Let me explain why we need a patient-centered medical home before I explain what it is If you go back in time to the 1970ís or 1980ís, the most common medical problems that we faced were infectious diseases ñ sore throat, pneumonia, someone breaks their leg, son gets sick There were mostly infectious disease problems ñ that was most predominant The system at that time was built on episodic care The patient comes to see the doctor, pays for that visit, it takes two to three days for the patient to heal, and then they are doing great! It takes months, and then something comes up. They go see the doctor again, they pay for the visit, and then they heal. They go home That is the system that we learned over the past 20 or 30 years ñ it is episodic The patient used to pay for the doctor ñ with money or other forms. It changed to insurance companies. Then Medicare came in a started to pay for patientsí visits Over time, the kinds of medical problems that we face as a nation have changed Now, because we are very good in medicine, patients are living for a longer time If you look at the average age in the 1970ís versus the average age in 2010, it has increased The average age of the patient is increasing because we are doing great in medicine We are preventing people from dying from heart attacks, stroke, and emphysema We have a lot of medicine that keeps patients doing well with these kinds of problems The problem is ñ now we are facing different health problems We are facing patients who have illnesses that live with them all of the time Patients who have osteoarthritis that is with them on Saturday, Sunday and Monday ñ that is with them when they see the doctor in March and is with them in June when they are not seeing the doctor It is the same thing with diabetes. Diabetes is with them all of the time Heart disease and heart failure ñ it is with the patient all the time But the health care system has not changed We still have diabetes. We live with diabetes all the time, but we see the doctor every 4 to 6 months. Sometimes we forget to see the doctor. Sometimes we forget our medicines But we are still treating the patients episodically The patientsí needs have changed We need to take care of the patient continuously, not episodically For the past 10 years, the healthcare systems have been thinking, ìWhat do we need to change in the system so we can take care of the patient with chronic medical problems? Problems that are with the patient day and night, all days of the week, every month of the year?î Here is where the concept of patient-centered medical home came from To change the thinking from episodic care to continuous care The other problem in the healthcare system is that when the patient goes to the hospital, there is a medical record in the hospital. The patient leaves the hospital and goes to the clinic, but that information does not go back to the doctor in the clinic The information does not flow between organizations That is why we have silos The patient has a medical record that is different between the hospital and the clinic That is why our healthcare is fragmented The way we pay for doctors right now is episodically There is no incentive for the doctor to coordinate care from multiple places This is where patient-centered medical home came from What is patient-centered medical home? This is the definition Patient-centered medical home puts the patients at the center of care, and it provides primary care that is accessible That means you get to see the doctor either physically or by phone or email It assumes the doctor is accessible and his team is accessible to you Continuous ñ no episodic Comprehensive ñ in which he takes care of the whole patient Family-centered ñ we engage the patient and their family Coordinated and compassionate This is a representation of the patient-centered medical home Payment – Instead of paying the doctor by the visit, the payment comes from the quality of the care for the patient That is the driver for us and healthcare organizations to change Access ñ which means the patient should have some form of communication with their providers It could be physically, but it should also be through phone or emails

Every patient is associated with a personal physician, and the physician will direct the practice. So there are multiple people involved in the care Now we associate patient to physicians, but the physicianís care is going to become physician with mid-level provider, with the nurse practitioner. And everybody is doing part of the care But all of them are under the direction of the physician We approach the patient from all perspectives, not just one disease Care is coordinated between hospitals and physicians Especially when we have multiple specialties So the primary care physician and his team needs to know what is happening when the patient goes to see somebody else Ultimately we are going to provide quality and safety to the patient This is another nice picture that depicts the same information Patient-centered medical home has enhanced access to make sure the patients have access to the physician and his team We as the providers have to identify the patients we are taking care of ñ the 500 diabetes patients, the 200 heart disease patients We need to have them in a list, know what they are doing and what they are taking and proactively manage their care Even if the patient is not at the clinic we have a team that looks ñ (Example) Mrs. Wells, did she have her diabetes test If there is a red box there that shows Mrs. Wells did not have her test and did not show up to the clinic, we give her a call Good morning, Mrs. Wells, you need your lab test done So this is proactive care The same example can be applied to medication If we know that Mr. Jones needs aspirin for heart disease and from our list we know that Mr. Jones is not on aspirin, we will give him a call This is planned proactive care Provide self-care and community support Because the patient comes to the doctor twice or three times per year, because there are new and multiple medical problems, we need to educate the patient about their disease At what point do they need to call the doctor? We donít want to wait too late in the stage of the problem for them to call us For example, a patient with heart failure: the moment they start having swelling in their legs, they should give us a call We donít have to wait until the legs are too swollen ñ by that time they would need to go to the hospital This is a simple way to prevent an admission to the hospital for congestive heart failure This is pain to the patient, pain to the family, and too much money for the system And too much money for the patients If we can teach the patients about the early signs and when to call the doctor, it is a win-win for everyone It is less money to the system, more cost-saving to the patient and less pain to the patient Track and coordinate ñ when we order a test, we want to make sure the test is done Multiple times we order a test and the patient does not do it Not intentionally ñ it could be the patient forgot, the patient did not have a ride that morning, the communication between the doctor and the patient was not adequate so the patient does not remember There are multiple causes for why when we order a test, the test does not get done In the patient-centered medical home we have to track what we have done to make sure it is being done Measure and improve Are numbers 1 through 5 causing the proof? Is it resulting in better care and satisfaction? That is the ultimate goal here ñ to make the patient more satisfied and healthier So we need to measure it Template for the future This is expanding it from primary care to hopefully specialty care in the future So what are the benefits? Better quality Hopefully we will have fewer emergency room visits Fewer hospital admissions Better preventative care services ñ immunizations, mammograms Better care for chronic diseases and higher patient satisfaction There is also less cost to patients and to the system because there will be less unnecessary tests and less duplication of tests So this is the patient-centered medical home I usually draw a picture. This is how I remember it, and hopefully I can do it Patients have accessÖ to the clinic Here are the doctorÖ and the patient They are using an electronic medical record, EMR, andÖ you can call it science, or evidence-based medicine or recommended care

As you know there are variations of how a certain physician treats diabetes in Temple versus how another treats diabetes in San Antonio As physicians we do not all follow certain recommended care In the patient-centered medical home, it is important that all of us agree as a community on recommended care for a certain disease When we do this and we have to track our orders and we have to educate the patient about their disease And hopefully that will result in better care We ensure the patient has access to the clinic ñ they get in When they get in the physician uses electronic medical records And itís important to use electronic medical records because physicians are dealing with multiple variables within 10 or 15 minutes There is no human mind that can remember all of the information that we need to do in 15 minutes and apply them So an electronic medical record helps remind the physician, makes it easy on the physician to know what happened somewhere else, and to make the information available at the point of care And use recommended care, and make sure weíre doing all of these things by tracking what we are doing, education patients, and following care to make sure it is improving These are the 6 parameters of patient-centered medical home: Access, EMR, recommended care, track, educate the patient, and make sure itís getting better I am open for questions Very good question The question is, is this a gatekeeper like we had in the 80ís? It is similar to what happened in the 80ís and 90ís but it is much better I think we learned from the mistakes that happened at that time In the past, insurance companies used to say to the doctors ñ Iím going to give you $100,000. You take care of the patients And thatís it. End of the story They did not put any expectations on the doctors That system incentivized doctors to do less That is why we donít like that. That is why the gatekeeperÖ I am going to lock you in this area and if I do not provide care I am going to win This is different This is saying to the doctors if you are able to take care of the patient and prevent hospitalization, improve preventive medicine, avoid duplication of tests, we can decrease the cost of this care for this patient population, and you have to show me that the numbers are better in the quality of care here If you can do all of these and you save this money, we can share that money between you and us Patient-centered-medical home is not a gatekeeper model This one is based on physician decision One of the differences is that the previous model from the 80ís was driven by administration ñ people who are not physicians Here they are saying, go back let the physician make the best decision for the patient In a primary care setting, yes Because he or she is going to be the person coordinating your care You can, but you have to ask your primary care physician first It depends on your insurance It is not a limited network. Again, there are multiple options In an HMO patient-centered medical home ñ yes, you have to ask you insurance But there are patient-centered medical home models that are based on PPO That means you still have your patient-centered medical home and your physician, but you can choose your specialists. It is an insurance difference and that one did not change You have to inform your primary care physicians, yes ñ even in a PPO Because the primary care providerís best interest is to look at- who is the best specialist to provide care? For example, if a primary care physician knows that a specialist is not providing the care that is needed for the patient in terms of heart disease, diabetes The primary care physician can speak with the patient and make an informed decision about choosing another (specialist) I do not think it is going to get to a point where I force you to see someone else

That is where engaging patient education comes in The decisions need to be made together ñ in the best interest of the patient With the patient. With the family to make the best decision with the family, yes Thank you Another question [Iím sorry, I did not understand her caveat.] She is saying when you make a decision to change a specialist, this is a decision made between the physician and the patient ñ together. It is a joined decision Is that what you are trying to say? Alright, OK Currently there are multiple options in Medicare We have the fee-for-service, which is the old model Medicare is telling us that this is going to shrink ñ it is going to change over time Medicare gives options for our clinic to do something called MSSP ñ Medicare Shared Saving Program This information is available on their website We can continue the fee-for-service, but it will incentivize physicians to prevent emergency room visits, prevent hospitalization, keep the patient healthy, keep the patient satisfied So there are incentives in that system to keep the patient healthy The third option is the Medicare advantage which is at the other end of the fee-for-service Think of medicine as art and science The science in medicine has been gradually increasing in medicine through the years If you go back to the 70ís and 80ís, most of medicine was an art You go and you learn. You become a professional and you make a judgment on what your professor told you and your experience These are the two sources Now healthcare is moving into more science, which means you make your decision based on what the evidence tells you That is where the physician has to decide between art and science So we apply the evidence-based recommendation ñ the best practices ñ but ultimately it is between the patient and the doctor to make the decision Did that answer your question? [So the doctor can go outside the recommended care and do something else for you?] If the recommended care was not done and it is in the best interest of the patient ñ talking with the patient, again to make an informed decision ñ yes The question is ñ would Medicare pay the doctor based on the quality they are providing? The model right now is the fee-for-service, which means Medicare pays irrespective of the result It is moving toward quality For example ñ the Medicare Shared Saving Program will give a clinic or group of doctors 50,000 patients. They will say we will continue paying you for your service, but if you improve quality ñ and these are the quality measures we want you to achieve ñ and if you are able to cut out all of the waste, the unnecessary tests, you can get some of that money that you are saving But you will not get that money if you do not show that there was a quality improvement This quality improvement is usually set by Medicare But we also see it with commercial insurance United is coming to us with the same discussion. Humana. Blue Cross Blue Shield It is not just Medicare Commercial insurance are coming to tell us that if you can prevent unnecessary care, emergency room visits and duplications of tests, we will give you back some of that money on one condition ñ if the quality of care has met these criteria: A,B,C,DÖ That is the difference between the 1980ís and now There are two questions. I am going to repeat your question – there is a problem at the national level with a shortage of primary care physicians And you are asking what physicians we have in the clinic Let me answer the quick one first In our clinic we have both family medicine and internal medicine physicians We are trying our best to expand the primary care knowing that this is what the population needs and wants Going back to your initial question ñ we do have a shortage in primary care I have two comments The Affordable Care Act provided more coverage to the uninsured But coverage does not mean access Someone having insurance does not mean they have access to a physician What is happening right now ñ there is a white paper that went before Congress a few weeks ago in February, and Congress is going to vote on it by the end of this year It shows changes in the SGR ñ Sustainable Growth Rate. It is a formula in which Medicare pays the physician And it is going to change to pay primary care physicians more over the next four years to encourage more medical students to go into primary care

Other solutions at some of the clinics ñ and we may go this route ñ primary care physicians or practices are hiring more mid-level providers and asking them to take care of the problems at the level of the mid-level providers. The nurse practitioners and the PAs Looking at other clinics ñ that has done very well in providing care for the patients She is asking why ADC does not accept Medicare Advantage insurance My response to her is that we are actively looking at that and it may change soon It is mostly because the Medicare Advantage that is available in Austin right now is through Humana. This is the most prevalent program So we are in active discussions with Humana about that [United Healthcare also has it] It does, yes, it does [But you are not talking with them] Not with United about Medicare Advantage, no, but you may see some changes in the future [What differences are there that they donít take that? What is it that they are objecting to?] I think it is on both sides Partially it is how they want things to be done and partially that we are growing to provide the care for Medicare Advantage Within episodic care, the clinics at a certain point cannot provide the Medicare Advantage kind of services With us building the patient-centered medical home, we are becoming stronger and better at giving the care the meets the Medicare Advantage needs This is why I am saying this is a parallel We are growing, and we are talking with insurance companies