Thursday, October 16, 2008

Establishing Medical Homes

An “Issue Brief” released at the Brookings Institution and the National Academy of State Health Policy forum on “Strengthening State/National Partnerships to Support Delivery System Reform” stresses the many challenges ahead for the healthcare system. Right now, there are rising costs and large variations in these costs, underuse of evidence-based care, and gaps in coordinating care for chronic diseases.

As mentioned in the brief, one of the solutions to the problems would be to initiate medical homes. States such as Vermont and Rhode Island are now initiating plans for medical homes. Currently, three Vermont communities are implementing the Vermont Blueprint for Health. The Blueprint includes a multi-payer primary care medical home initiative which is currently testing a combination of primary care payment reform, community care coordination teams, and how to provide health IT for patient care.

Vermont legislation authorized the creation of medical homes to enhance provider incentive payments in return for meeting nationally recognized functional standards. Healthcare delivery and public health prevention efforts are closely integrated in the state’s initial pilots. Each participating practice has access to local multidisciplinary care support teams, including prevention specialists that are shared across practices. In addition, practices are provided with a web-based clinical tracking system for tracking patient health information and producing population based reports.

Rhode Island has developed a two year statewide multi-stakeholder chronic care improvement initiative called the “Chronic Care Sustainability Initiative” designed to align quality improvement goals and incentives across the state’s health plans, purchasers, and providers. Beginning in January 2008 and continuing through December 2009, the initiative will provide enhanced payments to primary care providers for the delivery of high quality chronic disease care, including the establishment and promotion of medical homes.

There is news from other states to help develop medical homes, Massachusetts passed legislation (SB 2863) to give the state the authority to establish a medical home demonstration project and create a loan forgiveness program for physicians and nurses who agree to practice primary care in medically underserved areas.

The state of Washington passed legislation to establish patient-centered primary care pilot projects. With the funds available, the Department of Health offers primary care practices an opportunity to participate in a medical home collaborative program. The program will develop common core elements for consistency among medical home providers, provide standard measurements, and promote the adoption and use of the latest techniques to provide efficient patient-centered care. An annual report on the progress and outcomes of the collaborative will be published.

The Collaborative will explore partnering with the Washington Health Information Collaborative and the Health Information Infrastructure Advisory Board as the collaborative advances. The thinking is that if the health care authority makes grants to primary care practices to implement health IT during state fiscal year 2009, these grants should go to primary care providers participating in the medical home collaborative.

The Geisinger Health System serving Central and Northeastern Pennsylvania has nearly 700 physicians across 66 clinical practice sites, three acute-care hospitals, a variety of specialty hospitals and ambulatory surgery campuses, a 215,000 member health plan, and other services and programs. Geisinger’s 2.5 million patients are on the average, poorer, older, and sicker than patients nationally.

As an example of a success story, Geisinger has successfully implemented patient-centered medical homes. This means that round-the-clock access is provided to primary and specialty care services, nurse care coordinators and care management support is available, along with home-based monitoring. Physicians and patients have access to EHRs and are able to view lab results, schedule appointments, receive reminders, and email their providers.

The Geisinger system pays the practice group up-front to take care of patients and gives bonuses for meeting target levels for controlling blood sugar, cholesterol, preventing heart attacks, and cancer screening. Geisinger is providing practice-based monthly payments of $1,800 per physician, and stipends of $5,000 per 1,000 Medicare patients to help finance additional staff.

In other state news, two large health plans in New York are conducting a demonstration to promote medical homes by helping physician practices redesign their offices and revising the way that they are reimbursed for patient services. The project team will evaluate this demonstration to determine if it is feasible to transform practices into medical homes and to assess the impact that such a change can have on the quality of care, patients care experiences, and the total costs of care.

BlueCross Blueshield of North Dakota is developing a state-wide patient-centered medical home initiative called the MediQHome program. The program will launch January 2009 and will make it voluntary for physicians to be in the program that will include 4,241 providers with 1,433 primary care physicians and 2,808 specialists.

The initial program will focus on diabetes, hypertension, heart disease, childhood asthma, and chronic lung disease, immunizations, and ADHD. BCBSND’s MediQHome program will use MDdatacor’s, interoperable CareInformatix ™ technology to automate the collection of clinical data from physician practices from existing electronic medical records, and practice management, lab and registry systems.

The Iowa Department of Public Health has established the Medical Home System Advisory Council. The plan is to develop a plan to implement a statewide patient-centered medical home system. The initial phase will focus on patient centered medical homes for children eligible for Medicaid, the second phase on adults covered by the IowaCare Programs and adults eligible for Medicaid, and the third phase will focus on children covered by the hawk-i program and adults covered by private insurance and self-insured adults. There are also plans to allow state employees to use the patient-centered medical home system.

On the Federal government side, CMS is in the process of developing a Medicare Medical Home Demonstration to include up to 8 states with urban, rural, and medically underserved sites. The sample size will include 400 practices, 2,000 physicians, and 400,000 Medicare beneficiaries. On September 25, 2007, CMS selected Mathematica Policy Research to help design the demonstration which is expected to begin January 2010. At the present time, the demonstration design is not final and is being reviewed by CMS and OMB.

The CMS demonstration for develop of a medical home means there needs to be continuity of care, clinical information systems, delivery system design, decision support, patient/family engagement, coordination of care across providers and settings, and improved access to care.

According to this demonstration, there are two tiers of medical homes. Tier 1 provides basic medical home services and requires discussion with patients on the role of the medical home, written standards, data to identify and track patients, the use of an integrated care plan, the need to provide patient education, and the ability to track tests and referrals.

Tier 2 provides for advanced medical home services and requires the use of an EHR certified by CCHIT, systematic approach in coordinating facility-based and outpatient care, review of post hospitalization medication lists, and three out of nine additional capabilities.

Johns Hopkins University received a $1.7 million grant from the John A. Hartford Foundation to help the medical practices selected in CMS demonstration within the eight states to qualify for and participate in the project. With the funding, the Lipitz Center at the university will offer healthcare providers information, education, and technical support based on a Hopkins developed Care Model geared to help chronically ill older adults.

On Capitol Hill Representative Allyson Schwartz from Pennsylvania on September 27, 2008 introduced the “Preserving Patient Access to Primary Care Act” H.R. 7192. The bill supports medical homes and sets out provisions for Transformation Grants to support patient centered medical homes under Medicaid and SCHIP with $25,000,000 to be funded for fiscal years 2010, 2011, and 2012. The grants will go to states that design programs involving multi-payers test projects to recognize patient-centered medical home practices.