Patient-Centered Medical Home: Navigating through Recognition and Rewards
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Join athenahealth as we delve into Patient-Centered Medical Homes and the complications that come with navigating through the regulations to achieve level three recognition status.
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Patient-Centered Medical Home: Navigating through Recognition and Rewards
- 1. This event is live as of XYZ Patient-Centered Medical Home: Navigating through Recognition and Rewards Catherine Chuter Product Marketing
- 2. 50 years ago, half of all doctors in America practiced primary care. 2 Today, fewer than one in three doctors are PCPs.
- 3. Primary Care Crisis by the numbers 3 SOURCE: http://primarycareprogress.org/learn/the-issue http://www.nachc.com/pressrelease-detail.cfm?pressreleaseID=897 patients use ERs and Urgent Care clinics instead of going to a primary care doctor. Americans do not have access to adequate primary care. 1 in 5 60m+ 14% further increase in demand for primary care doctors by 2020.
- 5. 5
- 6. 6 First Line of Care Adults in the U.S. who have a primary care physician have 33% lower health care costs and a 19% lower chance of dying than those who see only a specialist.
- 7. April 16th MACRA, H.R. 2, made law • Strong incentives and support systems included to encourage PCMH adoption • APM participants may depart from the MIPS program and receive a 5% bonus each year (on top of any current APM payment structures) News from Washington:
- 8. MACRA (SGR repeal bill) represents continuation of the shift toward value SOURCE: The Medicare Access and CHIP Reauthorization Act of 2015; Advisory Board analysis. 2. APM participants who are close to but fall short of APM bonus requirements will not qualify for bonus but can report MIPS measures and receive incentives or can decline to participate in MIPS. Merit-Based Incentive Payment System1 2020: -5% to +15% 2019: -4% to +12% 2022 and on: -9% to +27% 2021: -7% to +21% 2018: Last year of separate MU, PQRS, and VBM penalties 2019 - 2024: 5% participation bonus 2019 - 2020: 25% Medicare revenue requirement 2021 and on: Ramped up Medicare or all-payer revenue requirements 1. Positive adjustments may be scaled by a factor of up to 3 times the negative adjustment to ensure budget neutrality. Actual positive adjustments may be lower than numbers shown here. In addition, top performers may earn additional adjustments of up to 10 percent. Advanced Alternative Payment Models22 1
- 10. Through MACRA health care professionals will receive a 5% bonus each year* just by participating in an APM and adhering to physician- reviewed quality measures. PCMHAPMs MACRA *Starting 2019 and continuing through 2024
- 11. Why PCMH?
- 12. What the Patient-Consumer Wants 12 SOURCE: 2014 Primary Care Consumer Choice Survey, Marketing and Planning Leadership Council interviews and analysis. For patients, access comes first. Service • Provider education on illness and wellness • Provider continuity Affordability • In-network status • Eliminated out of pocket charges Access and Convenience • Walk in availability, less than 30 minutes wait • Lab tests. X-rays, pharmacy onsite • 24/7 access • Same day appointment availability • Geographic proximity
- 13. 13 EHR Connectivity & Interoperability Data Registries Patient & Provider Portals Data Warehousing & Mining Acute Care PHARMAC Y SPECIALT Y CARE PATIENT/FAMILY SUPPORTS HOME CARE ACUTE CARE EMERGENCY CARE SUPPORTIVE /PALLIATIVE CARE TELEHEAL TH LONG TERM CARE Medical Home
- 14. Benefits of Becoming a PCMH 14 58% increase in clinician satisfaction 66% increase in staff satisfaction 11% increase in practice revenue 14% increase in clinician salaries SOURCE: http://primarycareprogress.org/pcmh L. M. Kern, R. V. Dhopeshwarkar, A. Edwards et al., "Patient Experience Over Time in Patient-Centered Medical Homes," American Journal of Managed Care, May 2013 19(5):403–10.
- 15. 15
- 17. PCMH Recognition Programs 17 Source: The Urban Institute, "Patient-Centered Medical Home Recognition Tools: A Comparison of Ten Surveys' Content and Operational Details”, May 2011
- 18. Nationwide Payer PCMH Programs 18 Source: http://www.theverdengroup.com/payer-pcmh-programs-nationwide/
- 19. NCQA PCMH Growth 2008-2013 19 SOURCE: http://www.ncqa.org/Portals/0/Events/BehindtheEnhancements_FINAL.pdf 214 1,976 7,676 16,191 24,544 34,492 28 383 1,506 3,302 5,198 6,762 0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 12/31/08 12/31/09 12/31/10 12/31/11 12/31/12 12/31/13 Clinicians Sites
- 20. PCMH Recognition Through NCQA 20 Six “Must-Pass” Elements ✔ ✔ ✔ ✔ ✔ ✔ 1. Patient-Centered Appointment Access 5. Referral Tracking and Follow-Up 6. Implement Continuous Quality Improvement 4. Care Planning and Self-Care Support 3. Use Data for Population Management 2. The Practice Team (Team-Based Care)
- 21. PCMH Recognition Through NCQA 21 Three Levels of Recognition ✔ ✔ ✔ Level 1: 35-59 points Level 3: 85-100 points Level 2: 60-84 points “The patient-centered medical home has the potential to change the interaction between patients and physicians. Patients can no longer be silent partners in their care— they are active participants in managing their health with a shared goal of staying as healthy as possible.” -Margaret E. O’Kane, NCQA President
- 22. Challenges
- 23. 23
- 24. Seek a PCMH vendor who follows these guidelines 24 Provides educational materials about the transition Determines where your practice stands for PCMH requirements Puts together a work plan for achieving recognition Connects with other practices that have successfully transitioned Advocates on your behalf with payers to ensure financial rewards
- 26. athenahealth was first to undergo NCQA PCMH Corporate Review 26 athenahealth covers about 60% of the points required for NCQA’s highest level of PCMH recognition 85 35.25 45.5 0 20 40 60 80 100 Minimum amount of points for NCQA Level 3 Practice Responsibility 4.25 Athena Enabled Auto Credit* NCQA Level 1 NCQA Level 2 *pre-validated NCQA points *practice support points athenahealth PCMH Accelerator Program
- 27. What’s Next? • PCMH Transition Resource Center: o PCMH2014 self-assessment o Guidance materials o Accelerator team o athenaNet support o Quality Management tools
- 28. 28 of our clients hold Level 3 PCMH recognition 77.3% of those recognized providers are on athenahealth 8% providers successfully recognized as a PCMH on athenahealth 4,072
- 29. 2014 Best in KLAS #1 Practice Management System (1-10, 11-75 physicians) #2 Practice Management System (Over 75 physicians) #2 EHR (1-10, 11-75 physicians) #2 Patient Portal #2 Overall Physician Practice Vendor “2014 Best in KLAS Awards: Software & Services,” January, 2015. © 2015 KLAS Enterprises, LLC. All rights reserved. www.KLASresearch.com
- 30. 30
- 31. Thank You
Notas do Editor
- Welcome and introduction
- Today we are living in what is known as the “Primary Care Crisis” or the “Paradox of Primary Care”. As a country, we have slowly moved away from the traditional, “Normal Rockwell”-type family doctor to patients using a specialist or an ER as their primary care. This is echoed in how many med students are graduating into specialties; understandable with the high costs of education and the draw of the salary of certain specialties. While there isn’t anything necessarily wrong with this progression, many governmental laws and practice standards have yet to fully adjust to this shift. Take a look at some of the facts. Sources: http://primarycareprogress.org/learn/the-issue http://www.annfammed.org/content/7/4/293.full.pdf Image source: https://www.flickr.com/photos/denisdefreyne/2496959629 Animation: Click once for first sentence, click again for second
- When people don’t have access to a regular primary care provider, they end up in emergency rooms more often, and they’re admitted to hospitals more frequently. In the average practice, wait times are long and the average duration of an appointment is only 8 minutes. As a patient looking for a new practice, it’s difficult to book an appointment and while any doctor would like to spend more time working with a patient, many simply are unable. As a result, huge populations of patients aren’t receiving recommended care. Without regular screenings or CCM, a patient with unmanaged diabetes can end up costing $102,000 on average per year in expenses instead of $12,000. Of the 2.8 trillion dollars spent annually on healthcare, patients with chronic diseases account for 75 cents in each of those dollars. The current system of delivery of primary care to patients clearly is not working for either the provider or the patient.
- There is a common view of primary care that defines it just as giving referrals, yearly physicals, and seasonal vaccinations but that is really only the tip of the iceberg. In truth, primary care physicians are responsible for making diagnoses and managing chronic diseases, also providing care coordination services alongside acute care management all while managing a patient’s complete health picture. That’s a lot of work. Especially when up against some pretty heavy statistics. Image source: https://www.flickr.com/photos/usoceangov/8290528771
- Primary care is and should always be the first line of defense for the patient. Our nation would save $67 billion each year if patients used a primary care provider as their usual source of care. Yet, with high tuition, years of intense study and training, debt, growing numbers of patient visits, and salaries considerably below those of specialty doctors, more and more medical students are choosing to maximize their incomes and electing to go into higher-paying specialties. A solution is clearly needed, and, along with many private institutions, the government is finally striving to help fix this problem. Sources: http://www.nachc.com/pressrelease-detail.cfm?pressreleaseID=897 http://www.commonwealthfund.org/Publications/Health-Reform-and-You/Primary-Care-Our-First-Line-of-Defense.aspx?page=all
- On April 16th, the Medicare Access and CHIP Reauthorization Act (MACRA), H.R. 2 was signed by President Obama. Passed by the House of Representatives on March 26th and then approved by the Senate on April 14th, this law represents an incredible showing of legislative cooperation. Many associations, such as the AAFP, fought hard to pass the bill. Had Congress failed to pass MACRA, physicians would have endured a 21% cut in Medicare payment, threatening access to care for some of the most vulnerable populations and leaving physicians with unpredictable payment. It is momentous to see a bipartisanship working in such harmony and to know our government has finally taken notice of the failed Medicare SGR and presented a fair and working solution. All told, it was a very strong win for both physicians and their patients. Sources: http://www.familydocs.org/payment-reform/macra https://www.acponline.org/advocacy/where_we_stand/assets/macra_handout_need_to_know_2015.pdf Image source: http://www.healthcarefinancenews.com/news/icd-10-debate-hits-washington-most-prepared-worry-persists
- Dive in a little deeper into payment systems coming out of MACRA. The bill permanently replaces the SGR formula with stable annual payment increases of 0.5% for 5 years. It also includes incentives for physicians to move into one of two value-based payment systems, based on their practice model, beginning in 2019. Both methods of payment will allow family medicine practices to garner better payment for providing improved care. These new payment systems are very much in opposition to a fee-for-service payment model and instead will incentivize practices to improve the health of the population, enhance the patient outcomes, and reduce costs. Additionally, the American Association of Family Physicians recommends that providers working in any size practice select option two, an APM such as a PCMH.
- Eligible practices paid under an APM will receive a 5% bonus on their Medicare billings for years 2019 to 2024. Starting in 2026, physicians participating in an APM qualify for a 0.75% annual increase. Again, it is important to note the core ideal that an APM rewards the progress away from fee-for-service to models that reward value and outcomes rather than activity or volume. More details: Now-June 2015: Eligible professionals who participate in Medicare will continue to enjoy the pre-April 1 payment rates, averting a 21 percent pay cut. June 2015-December 2015: Physician payments will increase by 0.5 percent. January 2016-December 2019: Physician payments will continue to increase by 0.5 percent each year. January 2020-December 2025: No further payment updates will be scheduled; rates will be equivalent to 2019 levels. Physicians will have the opportunity, however, to choose from two payment tracks with additional payment adjustments. January 2026 and subsequent years: Eligible professionals participating in the MIPS program will receive a single conversion payment update of 0.25 percent per year. Eligible professionals participating in a qualifying APM will receive a single conversion payment update of 0.75 percent per year. Source: http://www.familydocs.org/payment-reform/macra Animation: Click for paragraph
- Eligible practices paid under an APM will receive a 5% bonus on their Medicare billings for years 2019 to 2024. Starting in 2026, physicians participating in an APM qualify for a 0.75% annual increase. Again, it is important to note the core ideal that an APM rewards the progress away from fee-for-service to models that reward value and outcomes rather than activity or volume. More details: Now-June 2015: Eligible professionals who participate in Medicare will continue to enjoy the pre-April 1 payment rates, averting a 21 percent pay cut. June 2015-December 2015: Physician payments will increase by 0.5 percent. January 2016-December 2019: Physician payments will continue to increase by 0.5 percent each year. January 2020-December 2025: No further payment updates will be scheduled; rates will be equivalent to 2019 levels. Physicians will have the opportunity, however, to choose from two payment tracks with additional payment adjustments. January 2026 and subsequent years: Eligible professionals participating in the MIPS program will receive a single conversion payment update of 0.25 percent per year. Eligible professionals participating in a qualifying APM will receive a single conversion payment update of 0.75 percent per year. Source: http://www.familydocs.org/payment-reform/macra Animation: Click for paragraph
- The Advisory Board’s Marketing and Planning Leadership Council asked nearly 4,000 consumers about their on-demand care preferences across 56 clinic attributes and the most preferred was that a patient can walk in without an appointment, and is guaranteed to be seen within 30 minutes.
- A PCMH is a coordinated approach to managing patients that includes an emphasis on the integration of new technologies and teamwork. This then lead to returns on improved patient quality and improved patient health. While medical homes with payment initiatives and the number of states accepting many practices transforming into PCMHs have grown substantially, payments to primary care providers is still only 7% of total health care spending. To continue educating on and allowing practices to transition to a medical home and to provide larger payments for the increased cost of work, more providers must show support for this model to achieve it’s consistency in the health care community. Why should becoming a PCMH stand out as important? The reduced costs of care are very much measurable, along with other encouraging metrics. Sources: http://www.bostonherald.com/news_opinion/opinion/op_ed/2015/06/as_you_were_sayingfinding_care_close_to_home http://www.washingtonmonthly.com/magazine/july_august_2013/features/first_teach_no_harm045361.php?page=1 https://www.pcpcc.org
- In areas of the country where there are more primary care providers per person, death rates for cancer, heart disease, and stroke are lower and people are less likely to be hospitalized. A shortage of 20,400 PCPs is projected for 2020. Additionally by this year, a total demand for primary care will have increased by 14% due to an aging population and a population with wider access to insurance. However, if NPs and PAs are fully integrated into healthcare delivery, such as with patient-centered medical homes, this projected shortage of PCPs could fade to 6,400. Still more heartening, 69% of patients with access to PCMH care report the highest level of satisfaction at follow-up. Other great statistics: Patients with access to medical homes have 18% fewer hospital admissions, 36% hospital readmissions, and 7% savings in total medical cost. Only 10% of staff members in a medical home report a high emotional exhaustion at the end of the year, as opposed to the 30% of staff workers in non-medical homes. Sources: http://www.commonwealthfund.org/~/media/images/publications/health-reform-and-you/primary-care/pcmh-infographic.jpg https://member.carefirst.com/individuals/news/media-news/2014/patient-centered-medical-home-year-3-results.page http://www.hindawi.com/journals/scientifica/2012/432892/
- What does a PCMH mean for you, your practice, and your patients? At its core, the medical home is designed to provide comprehensive care that is patient centered, coordinated, and accessible all to deliver higher quality care. A patient-centered medical home in one such model: focused on keeping patients healthy and decreasing the use of more expensive medical resources. In short, PCMH means better care for your patient that is more cost-effective for you.
- If you’re now fully interested in becoming a PCMH, you might be wondering how you go about getting certified. There are many organizations supporting PCMH recognition, which allows you a range of choices. Animation: Click for circle
- Additionally to recognition programs, there are many commercial payer PCMH programs nationwide, well over 200 of them. These are the main programs with many subsets varying by state and institution. Source: http://www.theverdengroup.com/payer-pcmh-programs-nationwide/
- The most widely used and fastest growing PCMH recognition program is offered by NCQA, with more than thirty-four thousand clinicians and six thousand sites across the country participating at the close of 2013. Since this program is the most widely used and fastest growing, it is the one I’ll talk about in detail today.
- As any organization, NCQA adheres to a set of standards that emphasize how clinicians organize care around patients and work in teams to coordinate, track and improve care. While NCQA has recently updated their set of standards for 2014, their PCMH certification program is still based on the six standards and three levels of recognition you may be familiar with. Source: http://www.ncqa.org/Portals/0/Events/BehindtheEnhancements_FINAL.pdf Animation: Click once for all check marks
- A measurable point system goes along with these three levels. Six of six elements are required for each level. The score for each “Must-Pass” element must be greater than or equal to 50%. Source: http://www.ncqa.org/Portals/0/Events/BehindtheEnhancements_FINAL.pdf Animation: Click for all check marks, click again for dotted line and logo
- One of the biggest challenges you’ll face in moving your practice to a PCMH is time. It takes time to study and understand what procedures and standards your practice must now follow to gain recognition. It takes patience and increased communication with practice staff and ancillary staff to discuss all your patients’ needs as a whole and to allow for however long it may take to shift to a very different delegation of workplace tasks, including new training for nurses and office staff. Working around an already busy schedule you and your practice must be able to find the time for training, documentation gathering, adjusting to a new practice culture, and learning a whole new way of delivering care. While the cost in time and process disruption for practices adopting PCMH shows how carefully planned and patiently implemented the transition must be, if there ever was a time to start the process, in light of the new MACRA law, it would be now. Source: http://www.hindawi.com/journals/ijta/2012/103685/ Image source: https://scheong.wordpress.com/2014/03/10/a-rude-awakening-the-history-of-alarm-clocks/
- Studies have also shown that while using the right technology can help a practice become a PCMH model, the assistance of a partner with expertise in the PCMH transition can make that transition happen more smoothly and successfully. Your EHR and practice management vendor should not only provide the software to enable this transition, but should also provide the services to guide you through it. The ideal vendor will be committed to the PCMH model over the long term, continuously enhancing its software, services, and consulting services to support the model as it develops over time.
- Level 1 with NCQA requires 35 points and with athenahealth’s 35.5 baseline auto credits, you easily achieve Level 1 just by applying. What this means is, if you remember back to MACRA, this is an automatic earning of that 5% included within MACRA now. We are one of three vendors offering auto credits in this way but we are the only ones offering so many that you achieve PCMH Level One status right from the start. Only two other vendors who have any auto –creds (how many?) Animation: Automatic
- We’re more than happy to do about 60% of the work in helping you reach PCMH recognition, but what’s left for you to do and how do you do it? Before starting the process, visit our PCMH Resource Center to learn all about what tools, tips, and tricks athena offers to further support you and your staff as well as best practices for gaining even more PCMH points. From there, you can complete our PCMH2014 self-assessment to see your PCMH performance as of today. Activate the PCMH2014 Accelerator Program in athenaNet to begin tracking and driving your PCMH performance all with guidance and advice from athena. Our PCMH2014 guide matches each factor to workflows within athena as appropriate. After all that, you will receive NCQA auto-credit documents from athena to include with your PCMH application to NCQA. If any questions come up along the way, and they’re bound to, we have a team ready to help with whatever issues you may have.
- Clearly it’s working very well. Animation: Automatic
- As always, we strive to offer you the best possible services, etc. 64,000+ providers on athenaNet® Clients ranging from 1 to 5,000+ providers 50 states and 112 medical specialties $14 billion in client collections per year Acquired Epocrates March, 2013
- At the end of the day, it all comes down to the story of a doctor and a patient. Becoming a PCMH can help support this important relationship along with support from athenahealth.