[This Transcript is Unedited]

NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS

Subcommittee on Populations / Workgroup on Quality

PATIENT-CENTERED MEDICAL HOME HEARING

MAY 19, 2008

Renaissance Washington Hotel
999 9th Street, NW
Washington, D.C. 20001

Proceedings By:
CASET Associates, Ltd.
Fairfax, Virginia 22030
(703)352-0091

TABLE OF CONTENTS

P R O C E E D I N G S (1:00 p.m.)

Agenda Item: Introductions

DR. STEINWACHS: I’m Doug Steinwachs. I’m chair of the Population
Subcommittee of the National Committee on Vital and Health Statistics, and it’s
a pleasure to welcome you to our day and a half of hearings on the medical home
on trying to understand measurement. Both the concept itself, but also the
processes and the outcomes associated with the medical home.

I think we have an exciting group of presenters and I know that Dr. Justine
Carr, who is chair of the Quality and Data subcommittee, who co-sponsors this
session with the Population Subcommittee wants to add her welcome to you.

DR. CARR: Thank you. And thank you to all of the folks who helped set this
up today. This is tremendous. It’s going to a huge educational opportunity and
an opportunity also for a dialogue and exchange. So, I look forward to it and I
welcome you and thank you.

DR. STEINWACHS: As I think all you know, the National Committee on Vital and
Health Statistics is in its 59th year of advising the Secretary for
DHSS and predecessor agencies on both data and health information in the health
arena. Hearings are held to gather information to understand what are practices
in the community and to understand what are some of the issues that may be
relevant when we think about both national health policy and the data that
supports that.

Now, these hearings are being broadcast on the web and are being
transcribed. So, what you say becomes a matter of record. So, I don’t know what
that says about the jokes that Harry and I usually say. So, we’ll be more
careful than usual probably. Before we start, Id’ like to go around the table
and do introductions and then those people who are sitting around chairs
outside also to introduce themselves.

I’m Don Steinwachs. I’m at Johns Hopkins University and a member of the
National Committee on Vital and Health Statistics.

DR. CARR: Justine Carr, member of the committee and I’m also from Beth
Israel Deaconess Medical Center in Boston.

DR. QUINN: I’m Matt Quinn. I’m with the Agency for Healthcare Research and
Quality and I’m working with NCVHS.

MR. REYNOLDS: Harry Reynolds, Blue Cross/Blue Shield of North Carolina and
member of the NCVHS Committee.

MR. LAND: I’m Garland Land, Executive Director of the National Association
for Public Health Statistics and Information Systems and member of the
committee.

DR. FRANCIS: I’m Leslie Francis at the University of Utah and I’m a member
of the Committee.

DR. GREEN: Larry Green, at the University of Colorado and a member of the
committee.

DR. LINKMAN: I’m Larry Linkman. I’m from the University of Michigan. I’m a
practicing family doc and a guest of the committee.

DR. McGEENEY: Terry McGeeney, I’m with the American Academy of Family
Physicians.

MR. TUCKER: I’m John Tucker. I’m CEO of the American College of Physicians.

DR. PAWLSON: I’m Greg Pawlson, Executive Vice-President of NCQA.

MS. PARTRIDGE: I’m Lee Partridge, Health Policy Advisor, National
Partnership for Women and Families.

MR. NORTON: I’m Chris Norton, from IBM Healthcare and Life Sciences.

MR. COHEN: I’m Jim Cohen with the Center for Medicare and Medicaid Services.

DR. BETHELL: I’m Christina Bethell with the Oregon Health and Sciences
University and Director of the Child and Adolescent Health Initiative.

DR. MAXFIELD: I’m Miles Maxfield, I’m with Mathematica.

MS. KANAAN: I’m Susan Kanaan, and I’m a writer for the committee. I’ll be
writing a report about this hearing.

MS. CROSS: Hi. My name is Doria Cross. I’m an intern with the Agency for
Health Care Research and Quality.

MS. WILLIAMS: Hi. Kim Williams. I’m with the National Patient Advocate
Foundation.

MS. WHISTLER: Laura Whistler with the Blue Cross/Blue Shield Association.

MS. BUELL: Alison Buell, American Health Information Management Association.

MS. CAPP: Mary Capp, Centers for Medicare and Medicaid Services.

MR. MYERS: David Myers with the Agency for Health Care Research and Quality.

MS. JONES: Catherine Jones, National Center for Health Statistics.

MS. JAMISON: Lucy Jamison, National Center for Health Statistics.

MR. DELMONTE: Good afternoon. My name is Mark Delmonte. I’m from the
American Academy of Pediatrics.

DR. STEINWACHS: Welcome to everyone. I’d like to give a little bit of credit
before we get started to the hard work of the number of individuals that made
this hearing possible. In particular, Dr. Matt Quinn, who is with the AHRQ, and
has served as staff to the planning group here. And Larry Green has provided
the intellectual leadership for it. And some of the rest of us have tried to
join in with enthusiasm as we are here to learn, particularly Justine and
myself and a number of others who have worked very hard on it.

Staff has also been very active on it. Cynthia Sydney, who is staffing this,
as well as Debbie Jackson, Marjorie Greenberg will be here later, and Susan and
others have made this possible. My job, as Matt Quinn explained it to me, was
to keep us on time. That may be a challenge, but we do want to try to make sure
that in every session that we have chances for questions and dialogue as well
as presentation. So, that may be a little bit of a balancing act, but we’ll try
to see what we can do as well.

The first session is part of an overview, and we’ve asked three people to
provide us with different perspectives on the primary care medical home. You
should have in your book an agenda, and we’ll be following it with a couple of
cases. There may be some changes.

So, let me just quickly introduce the three speakers, each of which has been
asked to provide us with 5 to 10 minutes presentation, and that will leave a
few minutes for discussion before turning to the second half of that session.
It’s a great pleasure to have Dr. John Tooker here as Executive Vice-President
and Chief Executive Officer of the American College of Physicians, on of the
partners in coming together here to define where the key elements of the
medical home. And he will be talking to us.

We also have Dr. Gregg Pawlson, from NCQA. They just played an important
role in certifying medical homes, and as vice-president of NCQA, and very
importantly, it’s a great pleasure that we have Lee Partridge here from the
National Partnership for Women and Families to give us a perspective from the
family consumer side on the medical home at the same time we hear from the
others. So, please, Dr. Tooker, if you could lead off.

Agenda Item: Overview

DR. TOOKER: I’m very pleased to be here today on behalf of the American
College of Physicians, but also on behalf of the originators of the national
principles for the patient centered medical home. My understanding is that Doug
Henley, the EVP of the American Academy of Family Physicians was to be here,
but that he was unable to attend today. So, I’m trying to fill in and I talked
to Doug this morning as to what he might have said. Then, I will follow that up
in the next session with more specifics about who the current actors and
stakeholders are in the patient-centered medical home.

So, this will be at a pretty lofty altitude without getting into too much of
the specifics. A bit of the history is important and I want to begin by saying
that this is not an original idea. And I want to give the credit to the
American Academy of Pediatrics for developing a patient centered medical home
model for special needs children more than 40 years ago.

This idea was resurrected, and it’s been very successful in pediatrics. It
was resurrected by other communities, including the American Academy of Family
Physicians in their major effort to look at the future of family medicine in
about 2004. The American College of Physicians followed in 2006 with a major
physician paper called the Advanced Medical Home and together, with the two
Academies and with the American Osteopathic Association, the American College
of Physicians came together with those three organizations in 2007 to develop a
national set of principles around patient-centered care.

I think its important today as we talk about what it is to emphasize that we
don’t know exactly what it is yet because it is a concept that is now being
tested. It stems from the work of others initially in primary care and the
Institute of Medicine’s Work going way back into the 1970s about what are the
major attributes of primary care. And we focused on four of those key
attributes, and they are the first patient contact. That is to say that if you
are a patient in a patient-centered medical home and you need care, you have a
predictable contact that you call, 1-800-MY MEDICAL HOME, and you will have a
real entity on the other end who will take care of your needs now.

Two is that in addition to always having a home that you can reach in terms
of first contact that once you are a member of that home, you are a member of
that home. That is to say that care is continuous now. And it’s not episodic
care the way that so much of our fee-for-service care is today.

Three, that if you are a patient in that home, you should expect that that
home will provide a comprehensive set of services for you. And those services
are acute care services. They very much are chronic care services. And they are
preventive services now, a full range of services and that that care is going
to be coordinated. And I think it is readily apparent now that one of the
features of a medical home that patients value the most is that that home will
coordinate their care and the more complex the care of patients is, and it
doesn’t matter if it’s isobathic medicine, pediatrics, family medicine or
internal medicine, these patients, they need to see a lot of different actors
within the healthcare system, and one of their major issues is the ability to
A) have their care coordinated with a transfer of information to and from the
medical home appropriately now, and when I get into the second part of the talk
about what the model actually looked like in graphic form, we will exam those
relationships more specifically. But, those four elements of primary care are
key attributes of the patient-centered medical home.

And others have done a lot of work, both nationally and internationally, as
to how do you define medical home and how do you assess whether the care being
given is care consistent with primary care. In addition to that, it became
apparent that as patients developed more and more a chronic illness and for a
Medicare patient now, on average about 25 percent of Medicare patients have
five or more chronic conditions requiring a lot of care coordination.

And this care is best coordinated through team-based care. And team based
care is another key element of the patient-centered medical home. A credit for
this work, building on the key attributes of primary care, goes to Ed Wagner
and his colleagues at the McColl Institute at Group Health at Puget Sound, and
they developed the Wagner Chronic Care Model.

And that chronic care model is a model that I think you’re probably well
aware of, and is really designed to help specifically patients with chronic
illness now. Building on the attributes of primary care and taking those
attributes into a chronic care model, the four primary care societies that we
have talked about they developed these attributes further into the
patient-centered medical home to be able to care for, not only for chronic
illness, but also for acute illness and to provide preventive care to these
patients.

So, I want to emphasize probably repeatedly that what we are calling the
patient-centered medical home is built on the key attributes of primary care
and on the key attributes of the chronic care model developed by Ed Wagner and
his colleagues at Group Health, and I’ll show you those attributes in a second,
in which I have a model of the chronic care model that is well known today.

So, as of 2007, the key elements of a patient-centered medical home were
developed now. And the next major step along the way, and I’m glad that Chris
is here, is a very large national effort now to test the patient-centered
medical home. Greg and I have been on many programs about this now, and we’ll
talk about how you know a medical home when you see one.

And I want to emphasize where I heard the term certified medical homes, I
want to emphasize that we are not talking about the certification of a medical
home. What Greg will be talking about is the qualification of a medical home.
That is to say, how do you measure the key attributes of a medical home and
know when they are present.

And the reason that I am emphasizing that this is not certification is that
there are a lot of quality improvement organizations, including the American
Board of Medical Specialties who are very engaged in the certification of
physicians, and are increasingly wishing to be engaged in the systems-based
practice, and there is a lot of work going on now about how do you certify a
system in addition to the individual physician now.

I just want to distinguish the roles and responsibilities of these
organizations because they often times are confused. So, now that we have the
principles, we now need to implement those principles in pilots and demos and
that is being done as we speak, roughly 20 to 25 states now where models are
being tested. And they stem anywhere from individual models with individual
insurers all the way to large multi-payer, multi-player models with both the
government at the state and federal level, as well as with private insurers,
and we could not have done this work without a large collaborative called The
Patient-Centered Primary Care Collaborative, the PCPCC.

This is a large entity now, and Chris can tell you exactly how many players
there are because it changes frequently, but there are more than 128 members of
this collaborative, and they are critically important representatives of
patients, the consumers. And I’m really pleased to see the national partnership
here today.

In addition to the consumers, of course, are state and federal governments,
what others call the provider community and we are very interested in making
sure that all the members of the team are represented. And that includes the
physicians, nurses in the form of advanced practice nurses, and nursing medical
assistants, pharmacy, nutritionists, certified-diabetes educators, etc.

Because as patients become more chronically ill, they require a wider range
of services to care for them in this comprehensive environment, and it very
much includes the employers. And the self-insured employers and the leadership
of IBM have been remarkable in their support for this national effort. And they
helped a great deal in bringing along the health plans to the table as well.

I’ll talk about this more when we get to the current stakeholders and
actors, but I want to emphasize that all of the major players are at the table
now. So, we are at a stage now where this is a national movement. And it has
certainly moved on to the attention of MECPAC, as well as Congress. Right now,
this room is a little spooky to me because just a couple of days ago, we were
having our national meeting of the American College of Physicians here and we
were using this very room, although it was for a cocktail party and not for
this.

And just before that, I had been up on Capitol Hill with 500 of our members
and all 50 states and the District of Columbia and Puerto Rico and the
patient-centered medical home was very much on the minds of the staff, if not
the members of Congress right now.

So, the whole business now is getting this implemented. And I want to thank
you for the opportunity to testify before you because Health and Human
Services, particularly at CMS, where the Medicare Demonstration Project on the
patient-centered medical home is a big issue for us right now. These are very
important to us. So, I think I’m about at the limits of what my time is
expected to be for a general talk. I look forward to returning in the next
session for more specifics about what I’ve talked about so far. And I’m open to
any questions at your discretion.

DR. STEINWACHS: John, thank you very much. Why don’t we go through the other
two panelists and then come back for some questions and do it that way. So,
Dr. Pawlson, Greg?

DR. PAWLSON: John is on the board of NCQA, and I didn’t want him to have to
do my slides for me. That was not an appropriate thing. We will attest that I
sort of blanched when you said that because -–

DR. TOOKER: We can see that my main roots are not in the
certification/qualification world.

DR. PAWLSON: Well, it gets more confusing because in general, the term
recognition of qualification is sort of a relatively loose term of just how do
you know the characteristics of something. Whereas, certification has generally
had this sort of — although we use the term on the health plan and disease
management side sometimes — as well as then there’s accreditation, which is of
facilities and so on. So, it doesn’t apply to individuals. So, it’s easy to
confuse.

What I’m going to just touch on are a couple of concepts that are behind the
medical home. First and foremost is that I think there’s a strong belief, and
this is a model that John Berwick(?) and others have used in the past that
professionalism alone, or the marketplace alone, is not really sufficient for
healthcare and that what we are stuck with right now is great concerns about
both quality and cost. We can’t pick up any newspaper or any scientific journal
or anything else without having that sort of slap you in the face. And I think
it is particularly an international comparisons as well as comparisons within
the United States, the variation is much, much greater than any of us are at
all comfortable with.

So, this is sort of the pathway, and the medical home in a sense is a
pathway that is in the measurement area by being able to measure and look at
whether or not practices are functioning in medical homes, we would hope that
this information would primarily flow to the provider side and engage them in
quality improvement, and it’s really important to remember that, that this is
first and foremost an attempt to raise all votes. Not to just sort of mark some
practices as medical homes and other as never being able to achieve that.

I love this sort of -– that we have a medical sector or healthcare
sector. Mike Levitt, the Secretary of HHS, has used that to denote the fact
that we really don’t have a healthcare systems, and it really is -– the
only thing we really do in common is mostly because I think it’s CMS imposing
some order on this order, as we do have common voting systems.

It’s possible to get a bill on just about anything somewhere in the
healthcare system. And we really do have a system that I think is sort of the
patient family is sort of off to the side, and it’s the building system that we
are focused on. And one of the real appeals to me as a – my background is
in internal medicine, geriatrics and primary care –- is that the
patient-centered medical home really is a core piece of trying to create a
system of healthcare that is around integration by information systems and
organizations. And I think it goes well beyond the early concepts of primary
care in that it really builds on, as John has alluded to, the chronic care
model, which was all about systems and about information and about
organization.

And it also builds on I think, a growing research base that the Picker
Institute and others have created around patient-centeredness. We do not have a
patient-centered system at this point. Nor, do we have a patient-focused
system.

By patient-centered, I’m really referring to what happens in the clinical
arena between a patient and a clinician regardless of what kind of clinician.
And by patient-focused, I mean what happens in the rest of the system. So, why
don’t our medical records follow us around, rather than following the billing
system around? It’s a very interesting sort of concept I think. So, it goes
well beyond just the clinician interaction with a patient released as why can’t
we have a healthcare system that is person focused.

And that really says that the primary care patient-centered medical home is
really an important part, but so is coordination by hospitals and by
implication, the others laboratories, pharmacy and so on. And also, we’ve
talked about transformation that needs to occur in subspecialty practices as
well because many elements of the chronic care model, for example, not primary
care, but of the chronic care model, apply to specialty-based practices.

There is no reason why they cannot have information systems. Information
exchange, clinical decision support, patient self-management support for
patients that are predominantly care for by subspecialties. And this is the
last I’m going to talk about in this particular section. And it is really to
illustrate, and there is a few other things that I will talk about later on.

There’s the original concept of the medical home, which really is the sort
of initial formulation for special needs kids that did not really necessarily
include all the elements of the chronic care model, nor of primary care
particularly. But, this just shows that patient-centered medical home is an
amalgam of primary care of Wagner Chronic Care Model and of research on
patient-centeredness that really tries to pull all these things together in a
common framework around creating this entity that could be the core of the
healthcare system, but not all of it obviously, that will allow patients to
receive predominantly primary care that also has all of the features that the
chronic care model is actually patient- centered.

Now, the devil is in the details of teasing all this stuff out and
theorizing out how to really measure it in an accurate, reliable, and not
impossible manner, and then in applying the best tools that we have to find out
does this really –- do high functioning medical homes really have a
positive impact on both quality and cost and certainly on patient experiences
and charisma. So, that’s where I’ll stop.

DR. STEINWACHS: Greg, thank you. Next, we have Ms. Partridge, Lee.

MS. PARTRIDGE: Thank you. I’m please to be here to talk a little bit about
the patient-centered medical home from the perspective of the patient and the
consumer. Dr. Tooker and Greg have both mentioned, none of us are terribly
happy about the quality of care that is available in this country. And the
patient-centered medical home concept, especially with this emphasis on readily
accessible comprehensive coordinated care and active involvement of patients
and families shows real promise of being able to help us improve that system.

And therefore, the partnership has been active for several years and the
PCPCC – I can never get all the Ps and Cs straight. We also decided to
start talking with some of our consumer advocates in the field all across the
country about what they understood the word patient-centered meant.

And from that discussion, which took place about six weeks ago, we have
started to develop a set of what we call consumer principles for how we would
assess a medical home, partly because there are so many different definitions
out there. Greg and Dr. Tooker have been talking about a concept that is a
quite elegantly developed concept.

We have concepts floating around across the country that are much simpler.
In the interest of full disclosure, I should mention I’m a former Medicaid
director and I follow Medicaid very closely across the country. We thought we
were establishing medical homes with the PCCM systems 20 years ago, and indeed
some of them I think would come very close to meeting that definition today.

I can think of some really fine primary care practices in FH, federally
qualified health centers that would probably meet even the complete definition
the NCQA is talking about. Anyway, as a result of that conversation, we have
kind of a tentative guess of what will be on our consumer principles checklist.
And let me go over them briefly.

First, it would include access to a clinician 24/7. I think that’s an
element in most of the PCCM programs. That certainly is a requirement in the
Illinois medical home model that was launched for their Medicaid program last
year.

The second is what we call knowing about me, which means the primary care
provider should know my medical history, my treatment preferences, my family
situation and my support structure. We believe that all four of those are key
to helping make proper decisions or treatment course for that patient. If you
don’t like to take pills, you are probably not going to be terribly interested
in the treatment program that relies heavily on medication.

Third, and this comes up in all kinds of other situations as well, treatment
with dignity and respect not only from the clinician, but from all the staff.
Some of the work that’s been done – I think Greg can probably confirm this
–- on HMOs is that when you survey the patients, they will say oh I love
my HMO doctor, but I hate the plan. And it really means they don’t like the
front office helping me to see a specialist when needed and coordinating my
care with that specialist.

And finally, having public information available that allows me to see how
well the practice performs, not only on selected clinical measures, but also
patient satisfaction with that particular practice. One other element that may
be on our final list -– I think we think it should be on our final list
– is the one that talks about helping patients understand enough about
their medical condition to be active partners in their clinical care.

Dr. Lynn Mitchell, who is presently the Director of the Oklahoma Medicaid
Program is fond of saying that an informed patient is a better patient.
Patients and families should not just be passive followers of a clinician’s
advice, but should know enough about their condition and treatment options to
participate actively. The self-management concept that Greg had up on his
slides a couple of minutes ago. And this means that clinicians and Allied
Health professionals as well as patients may have to learn new techniques to be
able to participate fully.

And I was interested to discover last week that in the Vermont Blueprint of
Vermont, which is a medical home concept, they have done a fair amount of work
at the community level encouraging people to learn how to be good
self-managers. I would note that consumer would be weary of any new model that
sounds like the latest version of cross-cutting or gate keeping. They
immediately translate that into denial of necessary care or, at a minimum
increasing the hassle factor. It doesn’t mean that we will be necessarily
hostile, but if the argument in favor of adopting a patient-centered medical
home is to save money, consumers really won’t be motivated to choose it.

As we are going to talk more today, we will talk more, I’m sure, about the
diversity of models that are out there. They focus on different segments of the
population and use different incentives for provide participation and have
differing structures for implementation. One may emphasize patient education.
Another will emphasize practice redesign.

So, from our perspective, there is a tremendous learning opportunity opening
up before us. And that is one reason why in particular, we welcome this
committee’s interest in the concept. You have at your command here tremendous
research tools and I think we need to learn to use them to evaluate what seems
to work as this model rolls out, concept rolls out, vision rolls out across the
country.

DR. STEINWACHS: Lee, thank you very much. Let’s open it up to question or
comments. Well, let me start off then. To me, one of the big challenges has
been health literacy for all of us. And Lee, you were beginning to talk about
it at sort of a level higher than when we usually talk about health literacy,
when the doctor talks to me I can understand the words that translates. That’s
very different it seems to me than in a sense feeling empowered by
understanding enough about your care and expectations to have a dialogue with
your clinician about choices and pros and cons. Are there any thoughts about
how we get there since you had me stimulated?

MS. PARTRIDGE: Christine Bethell, down to my right, is a much better source.

DR. STEINWACHS: So, I should hold it until she speaks then?

MS. PARTRIDGE: I will say that the partnership that we have in looking a
little bit at some of the measures of patient activation and some of the work
that has been done by Judy Hibbert, for example, and some of the work that has
been done by Kate Loring at Stanford. I believe actually its Dr. Loring’s model
that is being implemented in the Blueprint on Health Structure in Vermont. I
think that piece is in its infancy or maybe kindergarten. Greg?

DR. PAWLSON: One of the real struggles, and I think we all would reflect
this in sort of defining the current patient-centered medical home model is how
much of it is aspirational and how far do you push when you get into certain
things that virtually no practices, a couple around the country are doing,
versus things that are sort of more foundational that many practices still
aren’t doing well. So, that’s going to be a constant struggle and I hope that
there will be some places that will sort of test more advanced concepts, if,
and I think really only if, they have some of the other stuff down.

Including, there’s different area of the country that are — like Minnesota,
the average practice there, at least on our total scores, in the 50s or 60s.
Whereas, we suspect as we’ve seen in Mississippi or Alabama probably score in
the 20s or less.

So, I think there is a lot of room for experimentation, but a lot of these
concepts are not horribly well tested and especially in terms of their impact
on quality and cost however we measure that.

DR. TOOKER: We have to decide what we mean by health literacy. To some
patients, and it’s at the level that is so basic that they cannot read, but if
you think about what Lee has said about dissatisfaction with the individual
physician, but not with the HMO, what typically happens when you are a new
patient in a practice?

The first thing that happens is someone hands you a clipboard and asks you
to go sit down and write out three pages, double sided, and don’t talk to me
until you’ve got that done. And there isn’t any way of knowing yet, with the
initial exposure to practice, whether that patient is literate with respect to
their health needs or not.

Two, they may read very well and that their level of understanding in lots
of things is normal, but in terms of health literacy, they find it overwhelming
and very confusing. My point is that in order to measure it, we have to develop
better tools to assess health literacy of patients and allow them to
participate in something like the patient-centered medical home.

In addition to the need to develop tools, we don’t know very much about how
to interact with patients to be able to measure it because patients can find it
very insulting if you translate health literacy into your dumb and that you
need to be talked down to in terms of your care.

And you cannot activate a patient in a practice unless they feel, and it’s
really telling in Ed Wagner’s graphic about the chronic care model, that the
patient is on exactly the same plain as the practice team is now. That they are
viewed as equals. So, how to change the relationship so patients feel that they
are equal partners in their care. And while an informed patient is critically
important, an activated patient is even more important.

As Lee mentioned, using tools such as June Hibbert has developed to actually
measure and assess patient activism in their practice. And also, with respect
to measurement, I think it’s important for the panel to know that the
patient-centered medical home is an accountable entity to all of the parties
that the home relates to. And particularly in including patients, it must have
tools in place to be able to demonstrate to patients that this is not a
gatekeeper model, but rather this is a voluntary home in which they can make a
decision whether or not they want to be part of that home or not.

DR. STEINWACH: Larry, you had a question or comment?

DR. GREEN: I do. I actually have two questions -one for Lee and one for
John. Lee, if I heard you right, you indicated that you thought that normal
people trying to get health care in this country would be wary of anything that
sounded like gate keeping or had an attitude that the main reason to do this
was to save money?

MS. PARTRIDGE: Right.

DR. GREEN: Can you just keep talking about that now? What is that all about?
And I’ll ask you to put it in a context that the country has to figure out some
way to save some money.

MS. PARTRIDGE: Right. And I certainly think that consumers are equally
concerned about holding costs down. I think that still some of the old HMO
flavor carries over and there is concern – suppose I’m –- well, I can’t
use IBM because IBM is doing this and you’re doing it well. But, suppose I’m a
major employer and I’m trying to encourage you to choose a patient-centered
medical home practices as opposed to others? I don’t think that the message to
your employees can be that the primary reason that we want you to do this is
because it’s going to hold, even your part of the premium down – although that
might be a somewhat effective incentive.

I think it has to be explained to them in a much more positive way. Or else,
if you are talking about a voluntary system, you’re not talking about a
mandatory gate keeping system, and some of the Medicaid programs are mandatory
gate keeping systems, but, if you’re talking about a non-gatekeeper system, if
you’re talking about a voluntary system, that can’t be your central message.

DR. GREEN: My question for John was a political one. Could you share with us
what in the world happened a few years ago when you got the pediatricians, the
internists, the family physicians, the osteopaths all to agree about something
at the same time?

DR. TOOKER: Well, interestingly, Larry, the pediatricians, family
physicians, and general internists, usually agree. But, we have been thrown,
particularly family medicine and general internal medicine, into this same very
difficult pot right now.

And that is what we referred to in a report to Congress of the collapse of
primary care. Primary care is collapsing in this country. And we are trying to
ring that bell very loud that we are at risk now of losing primary care in this
country. And I think the bell has been heard. MEDPAC has said, in Congress last
week staff and some of the members said that we are very worried about primary
care at the level of the Senate Finance Committee, and as I said, at MEDPAC.

So, Larry, I think that a galvanizing issue and it’s certainly highlighted
in the future of family medicine, a project as well as our own paper was that
we are very worried. Not just for the profession, but particularly for patients
who said that they highly valued having their own primary care physician now.
We must change the financing system and the payment system in this country if
we are going to be able to provide a primary care physician for patients.

And this model is a physician-led model, but I wanted to emphasize that this
is a team-based model that fully incorporates to the level of their training
and licensure many other professionals. I also wanted to briefly mention that
cost efficiency is a very important part of this concept.

It’s not meant to limit the expenditures of payers primarily, but rather for
the patient’s benefit because patients now are increasingly paying a larger
part of their healthcare out of their own pockets now that we have to
understand both clinical effectiveness and cost effectiveness of care. And the
ACP just released yesterday, published a paper on the need for cost effective
care as well as for clinically effective care.

As Lee said, the primary reason cannot be to restrict services or to lower
payment, but we know that there are many services today provided that are not
necessary. And if you look at the relationship across steps just under
Medicare, the amount of money paid per beneficiary from one state to the next
varies widely, without any improvement in the quality of care.

So, I think in order to have an activated patient, I think that they have to
understand what the cost implications of their care are, as well as the
clinical implications. And again, it’s not to restrict service, but rather to
have an informed patient. They need to know what the consequences are of the
cost of their care, as well as the clinical effectiveness.

DR. CARR: Actually, Matt just shared a note with me, and it kind of
underscores what I was going to ask as well. You touched a little bit about
what it means to testify in front of the NCVHS, and I want to just say a few
words about what we saw as the role of this, and also hear from you because
there is so much going on nationally, but what are the areas that we could
uniquely help with. But, let me just reiterate what Matt has here.

The goals that we identified at the outset were four. One was to bring
together stakeholders for shared concepts and definitions. The second was to
understand the measures and the dataflow, the standards, and existence,
performance and value. And the third is use of datasets for measuring
patient-centered medical home, and fourth, means to incorporate the
patient-centered medical home requirements into health IT systems.

So, those are things that we thought about, but I think it would be very
important to hear from you how should we –- is there something else we
should be thinking about, or a way that we should be listening to what you’re
telling us so that we’re certain to get the right message?

DR. TOOKER: If you can do all of what you just said.

MR. BREEN: Can I just ask one question? One thing I didn’t really hear much
about. You said this would be a voluntary system and I know Lee Partridge, you
said that you used to work for Medicaid. So, you know that there are some
systems out there. Often times, they are badly under funded or they are set up
in a way where. Well, sometimes, even the voluntaryness of it undermines
cost-effectiveness of the running of the thing.

So, I’m kind of surprised that you’re not talking about funding mechanisms
because too me –- well, I’m an economist — but to me, that’s something
that really should be considered at the same time as you’re thinking about this
that maybe we don’t want a voluntary system. Maybe we want a real system
because people have talked about risk pooling and that voluntary systems tend
to undermine risk pooling. They can lead to the kinds of inefficiencies that we
have in our system where specialist do an enormous amount of work that
generalist could be doing and probably should be doing.

And then a lot of people don’t get care at all. And then there’s quite a lot
of over care. I work at the National Cancer Institute and we’re starting to
question whether all the screening tests need to be done as frequently as they
are. So, there’s a lot of inefficiency shall we say within a system that can be
created by a voluntary system, which maybe could be smoothed out through
thinking about the financial mechanisms as well. So, I wonder if you’ve been
thinking about those and if you’re thinking if you put a good system together
and some economist will come and help with financing part or how that fits in?

DR. TOOKER: Those are terrific questions, and yes, we have been thinking
about them a lot. We are somewhat constrained now by the fee for service model
that we have, both in the private sector and the public sector. That is to say
that and I want emphasize that for family and internal medicine, we are talking
about where most of the care in this country is delivered and these are in
small ambulatory practices.

At ACP, roughly 50 percent of our practices are four or less and about 20
percent of our members in practice are still in solo practice. So, we have a
huge number of very small entities out there providing the bulk of ambulatory
care in this country.

And these are small businesses. So, they have learned to survive by
developing their workflow relative to the payment system that they have. And
that payment system is that you get paid primarily for the number of face to
face visits that come through your office just now.

In order for the patients under medical home model to work, that has to
change. While we think that when patients need to be seen at the present time
that a fee for service should continue, but when we are faced with the burden
of chronic illness and how to manage it, these patients need to be managed in
between their office visits. And I would say that when I was in practice that
if I saw a patient, if I said, I’ll see you in three months, I wouldn’t have a
clue whether or not I really needed to see this patient in three months or not.
But, I did know that that patient with chronic lung disease needed to be
managed in-between these visits.

So, what we ware saying is that there still needs to be an additional
payment. And that payment is per member per month the care coordination
payment. And it’s tricky now trying to look at this balance now. Is that a
fully capitated payment, which these small practices are going to take risks,
or is it not? And at the present time, it is not. But, there is going to be
some pressure for practices to be efficient, but we are not advocating
capitation at this point, but rather a per member, per month payment to manage
the coordination of these patients.

Now, how much does it cost to coordinate the care of a patient? Nobody
knows. And for that reason, we have engaged the Urban Institute with a grant
from the Commonwealth Fund to do a costing study to see what it really means
when we say that we are going to pay for care coordination now.

And as an economist, you will quickly see that this is fairly complex in
that for the current business model, for those patients that you would normally
see and get paid a fee for service, if you’re not seeing them, and then you
have to make up that reimbursement by the care coordination now.

And the practice will need to increasingly be able to get information
outside of face-to-face visits in order to manage patients. So, that means
understanding what remote monitoring is for blood pressure, for blood sugar,
that this information comes into the practice and allows for patients to be
managed outside of the practice. How do you pay for remote monitoring security
mail messaging? And we’re beginning to understand that now. So, it’s another
form of payment.

And there may be payment associated with performance. These are accountable
entities in which the practices will be measured. And all of us are heavily
engaged from measured development at NCQA and the PCPI through the endorsement
measures of the National Quality Forum to the implementation measures through
the AQA, HQA and the Quality Alliance Steering Committee, and I won’t bore you
with all of that except to say that there is a tremendous amount of work going
on now to develop increasingly complex measures to understand how that system
of care is being developed. And those measures need to be implemented in
practice with the information systems available to be able to obtain the data
to satisfy those performance measures.

That also includes care coordination, and I think we will get to the point
where we get into cost efficiency of a practice now. And what is tricky and we
don’t know enough about yet is that if you save money, both on the ambulatory
side by fewer non-evidenced based referrals to understand now that patients can
go wherever they want. We know that there is a big difference in utilization
services between South Dakota and Florida in terms of how services are being
accessed now.

We can reduce the number of non-evidenced based referrals. Now, by having
informed activated patients know that it is not in their best interest to go
seek a bunch of referrals. They are not coordinated with their medical home.
How do we recognize those savings and benefit from them. And we are looking at
shared savings models now between the patients at a medical home and the
referral base in which there is a cooperative relationship between the patients
at a medical home. Probably though, in response to your question, a bigger
source of savings, but I’m out on limb here, is the savings between Part A and
Part B money.

For these patients who have carefully coordinated care, and I’m a
pulmonologist, so if I have patients with asthma, for example, these patients
should not end up in emergency rooms if there care is well taken care of in an
ambulatory basis.

So, if they don’t end up in emergency rooms and they are Part A savings, how
do those savings accrue to the people who are doing the work to keep these
patients out of these Part A environments now? And of course the same thing
applies to hospitalizations now. So, we have to have a larger national
discussion about saving money and the aggregate. It’s compounded even further
though because you want patients who are not insured to all be enrolled in
patient-centered medical homes and the most complex patients need to be really
enrolled in patient-centered medical homes and we can’t have mechanisms where
practices don’t want them because they are too hard to take care of now.

You’ve got to incentivize these practices to be able to care for the most
complex patients in these medical homes. And to their credit, the American
Hospital Association has had a recent large initiative in which they have
talked about the relationship between Part A and Part B and have talked
particularly about bundling of payment and have recognized the importance of
the patient-centered medical home. So, I’m sure we could have several days of
conversation about your question, but I just wanted to let you know at a very
high level that we understand the issues and are trying to understand some of
the answers to those.

MS. PARTRIDGE: Can I just add a postscript to that? Another thing we might
look at as a model is the new special needs plans in Medicare. Because, in
addition to the problems of Part A and Part B, with two separate sources of
funding, you have Medicare and Medicaid, with two very different sources of
funding.

Dr. Tooker and I have talked about this a little bit. The incentives are all
wrong. As a Medicaid Director, I am not going to save any money by fewer
hospitalizations. My money is on the outpatient side. Ditto, you don’t care
about what I do in community based care.

These programs are so new, but I think maybe in a couple of years we could
– maybe a year – we should be able to dig into the track record of
some of them and see what the cost implications have been.

DR. STEINWACHS: Well, thank you very much. This has been a great kickoff to
think about the vision of what the patient-centered medical home and the roles
that it will play. We were going to turn next to talking about who are the key
actors in the patient-centered medical home and stakeholders that are here.

So, we are fortunate to have Mr. Jim Coan from CMS, who is in the Office of
Research, Development Information in the Demonstrations Program talk to us from
the CMS perspective. And Mr. Chris Nohrden from IBM, and you’ve already gotten
very positive feedback and that’s good, isn’t it, about the employer side of
the stakeholder picture here, which is a very important part in the American
healthcare system.

We had hoped to have Susan Edgman Levitan with us, but her health didn’t
permit. So, Lee, if you end up having some additional comments about
stakeholders, we’ll bring you back in. And again, we have the pleasure of John
Tooker to talk about stakeholders from his perspective. Jim, do you want to
lead off?

Agenda Item: Key Patient-Centered Medical Home
Actors/Current Patient-Centered Medical Home Stakeholders

MR. COAN: Thank you and thanks for having me today. I appreciate it. From a
CMS point of view, Medicare demonstration is a research project. Mimicking what
has been said a little bit earlier, there is still a lot that isn’t known about
medical home and how medical homes work. And whether or not there is any
benefit to any particular kinds of medical homes. There’s a lot of good work
going on out there, including the work for IBM. I want to jump on that
bandwagon too please.

There is a lot of work going on. And it’s very good and it’s very
informative. But, as far as actors and stakeholders are concerned, as the days
go by, we find that we have more and more actors and stakeholders in the area
of patient-centered medical homes, and it’s for good reason too. The thing to
keep in mind with actors and stakeholders is although we might agree in
principle on the basics of what medical home care ought to look like or what
the medical home ought to be, depending on who you are, it’s how you apply the
medical home that is going to be the difference. And there are various needs.
We’ve heard a few of them already up to this point.

For example, we hear that there is a clinical quality need for example. It’s
very important. Clinical quality is very important in the establishment of
medical home and medical home type care. They also have a stake in payment,
which was also brought out. So, there’s a clinical quality principle that has a
stake in the payment side of things.

Now, from the CMS point of view, we happen to be a payer who has a stake in
the quality aspect of it. So, it’s a little bit different. We have to try and
find some more of the middle ground. All of the actors, all of the players have
to try to establish what exactly we’re talking about and how it ought to be
compensated.

Depending on what you need, depending on what you’re particular agenda item
might be, you have a tendency to look at medical home in terms of how can it
satisfy that need. We can’t prioritize all the needs. We can’t put all the
needs in some kind of a chart and determine where the priority needs actually
are because we’ll argue endlessly.

We recently, because of legislation that we got -–- I’ll go into that
in just a few minutes by the way -– we recently engaged the Relative Value
Update Committee from the American Medical Association to establish the
relative value units to price the medical home monthly fee for medical
demonstration. There were 12 individuals on a workgroup that created
recommendations that the overall ruck agreed on just at the end of last month.

And we had several weeks of telephone calls. Twelve individual, 12 very
different points of view. Twelve individual stakeholders all deciding on one
thing. They pulled it off. They did an excellent job. I was remarkable. But,
there was a lot of push and pull and give and take simply to establish what the
rules were and what the needs were. Are my needs being met in this group and so
on? I thought it was important to start out talking about stakeholders and
actors and giving a perspective in terms of the fact that there is going to be
certain needs that are not necessarily identical up and down the line and
there’s going to have to be some understanding that the first thing we need to
do, we have to build the house before we furnish it.

So, let’s figure out what it is medical home does and doesn’t do. And then
figure out how we can make it work in a more universal sense. Quickly, I’ll go
through some slides. It will describe for you what Section 204 of the Tax
Relieve and Health Care Act of 2006 tells Medicare, tells CMS what it is we
have to do.

We’re directed to redesign a healthcare delivery system, providing targeted,
accessible continuous coordinated and family center care. Provide care
management fees, and provide incentive payments, all directed at a medical
home. Medical home is intended in the demonstration to be focused on high need
populations, which is described as individuals with multiple chronic illnesses
that require regular medical monitoring, advising and treatment.

This is what the legislation tells us. We don’t want to build a chronic
disease medical home. We want to build a medical home that’s good for the sick,
that’s good for the ill and the seriously chronic ill. We want this to be
general fully functional medical home that would apply to anybody. But, our
focus for the purposes of the demonstration is that these people be diagnosed
with chronic illnesses.

We have taken an interpretation because of certain ambiguities within the
language of the Act to make the indivdiual’s Medicare beneficiaries who have at
least one chronic illness that’s determined from a list of chronic illnesses
that we are working on right now. That is to make sure that it is important.
For example, many Medicare beneficiaries might have essential hypertension and
hyperlipidemia, neither of which would lend themselves to very much improvement
in medical home type care.

We’re really looking for the medical home to be applied to the kinds of
chronic illnesses that lend themselves much better to the care coordination.
We’re not saying anything is less important or more important, but merely for
the focus of the demonstration, which I emphasize again is a research project,
we want to see how well it works for people who are likely to consume those
services in larger quantities. And also consume a greater portion of the
healthcare dollar.

Ninety populations, 83 percent we estimate of Medicare beneficiaries have at
least one chronic condition. We know now from the list that we aware working
on, which is predecisional list, we can’t tell you that this is the way it’s
going to be because we’re still waiting on approvals and other such things.
But, with our list, 86 percent of Medicare beneficiaries who participate in
medical home will be eligible because of the chronic conditions. They will have
at least one chronic condition.

We also know that 23 percent is similar to what Dr. Tooker mentioned
earlier. Roughly 23 percent have five or more chronic diseases. That’s pretty
important. Break that down a little bit. They see 13 physicians on an average
per year. They fill an average of 50 prescriptions. They are most likely to
have preventable hospitalizations, which is an important factor to apair. And
also, they have the highest out-of-pocket cost.

Our demonstration is intended to run for a three year period. We’ll do it in
no more than eight states, which have not been chosen. The demonstration will
have to apply to practices that have three or fewer full-time equivalent
physicians. And we’re emphasizing physicians in large practices as well,
particularly, those in rural and underserved areas.

To be a medical home, practices could also be specialties or subspecialties
if they are providing a significant amount of primary care to the patient. By
definition, we’re pretty much tracking along the lines of the joint principles
that AAFPACP/AONAP are using because, let’s face it, they’re right. There’s no
sense in arguing that.

It will be a physician based practice providing safe and secure technology,
promoting access to personal health information, using health assessment tool
and so on. This is just very brief, but I think we would probably tell you to
look to the joint principles if you wanted know what kind of medical homes we
were envisioning.

To qualify as a medical home, it’s a voluntary procedure. We’re not going to
go out and establish medical homes by force. We’re going to invite practices in
all of the eight areas that we choose to become medical homes. We will use a
process very similar to the Physician Practice Connection and patient centered
medical home that NCQA has developed.

Once again, it’s one of those things where it already exists and there’s
really nothing that we could do to it to make it improved. So, what we’ve done
is we’re working through our contractors to develop a modified version of that
that will apply to this demonstration only. And it will not have an affect on
NCQA’s PPCPCMH tool. It will just very closely resemble it.

So, all the practices will have to meet those standards. And they’ll have to
agree to maintain or remain in the medical home demonstration. We will pay a
monthly fee for the personal physician in the medical home. That would be a
PMPM. A per-member-per month monthly fee for each medical beneficiary and a
demonstration so long as they maintain their eligibility.

Their expectations are improved coordination that will lead to improved
outcomes and improved outcomes that will lead to lower costs. Cost savings
could be used for additional incentives. The legislation tells us to do that.
And basically, the way we’re looking at it is when the patient does better, the
practice does better.

So, that’s from a stakeholder point of view who happens to be a payer who
also has a stake in quality. That’s an overview of what the demonstration is
probably going to look like. There’s no details here obviously became we were
in a pre-decisional developmental portion of our demonstration design. So, I
can’t go into a great deal of detail. And I’ll leave it at that. If there are
questions later, I’ll be happy to answer.

DR. STEINWACHS: Jim, thank you very much. Why don’t we go on to Chris? You
want to talk about the employer perspective?

MR. NOHRDEN: Thank you. I’m the project manager for IBM’s patient center
primary care initiative. And I’d like to thank you very much for this
opportunity to address you today. The perspective I do want to share with you
is that of a large employer, but also a significant buyer of healthcare in the
U.S.

We spend currently close to $2 billion annually to provide healthcare
insurance for about 600,000 lives across the country. And we’ve had a
continuing emphasis on quality, cost, and access to care for a number of years.
And that’s helped us maintain our health insurance premiums among some of the
lowest in our industry.

We’ve also had a special emphasis on wellness and wellbeing programs and
health promotion, which have similarly reaped significant benefits and savings
to a tune of about $175 million worth of savings annually to the IBM
Corporation.

But, as a large self-insured employer, our health benefits costs are
basically costs of doing business. And we require the steady focus on our cost
structures to make sure that we can remain competitive in our industry. But,
quite frankly, we’re really not very happy with the quality and the cost of
care that is currently available on our fragmented healthcare system.

The statistics about healthcare quality are particularly disturbing. If you
consider the estimate of Dr. Elizabeth McGlynn and others in her 2003 New
England Journal of Medicine article that adult patients only receive the proper
care for chronic conditions about 50 percent of the time. Our average employee
age is approaching 42, and many or them are entering their mid-life decades
when they may begin to experience multiple chronic conditions. Our feeling is
that these chronic conditions would be much better dealt with in the context of
a trusted primary are relationship with a primary care provider. Rather than
the later stages of development as is currently the case with our third party
disease management identity.

This is not one of the prettiest examples, but we currently have the
reimbursement systems in place that will reimburse specialists $20,000 for a
diabetic leg amputation, but we don’t have the mechanisms in place to pay a
primary care provider for the process and procedures and the infrastructure
that will allow them to use patient registries and clinical decisions support
tools and other types of IT tools at the point of care to get things like
annual foot exams and other recommend treatments that will prevent these
problems from occurring in the first place.

About a year ago, we began a dialogue with our primary care providers to
understand how we could change the paradigm for the type of health care and the
quality and the cost factors in particular and discover the concepts of the
patient center medical home that was postulated and deposited by the American
Academy of Pediatrics and which has now been endorsed by the other three
primary care professional associations.

As you’re going to hear more I think and through the testimony a
patient-centered medical home for primary care requires a long-term
relationship. That’s one of the primary things that we’re looking for, with a
trusted primary care provider that’s enabled by technology to provide much more
meaningful preventative care and wellness coaching.

And this may include elements such as email consultations, electronic health
records and clinical decisions support to all sort of link with evidence-based
guidelines of care. And currently, outside a number of our health maintenance
organizations, we can’t buy this type of primary care in the United States. But
remarkably, it’s a very successful model for the delivery of primary care in a
number of other countries like Denmark, New Zealand and Singapore. And I’ll
speak a little bit about that tomorrow in the context of Denmark.

So, in 2007, we brought together the primary care professional associations,
other leading large employers, and the payers to create what John Tooker has
already alluded to the Patient Center Primary Care Collaborative. It’s a
mouthful. We don’t have a clever acronym for it, and we’re struggling. It is
certainly a multi-stakeholder collaboration. It’s based here in Washington D.C.
It’s hosted under the umbrella of the ERISA Industry Committee. And it really
provides the form for the policy discussions that we need to have about how we
are going to obtain and pay for this better model of care.

The collaborative now represents about 50 million American lives, and it’s
been signed on to by upwards of 100 leading employers, including those such as
Boeing, Caterpillar, Fed Ex, General Motors, among others. Of course, our
professional associations, professional provider associations and seven of our
national health plans. We had a national summit last October here in
Washington. We are honored to have former speaker of the house, Newt Gingrich,
speak to us. And one of the most pithy quotes that I took back from that is
that technology, prevention and consumer-centered care are the powerful forces
necessary to transform healthcare into a 21st century intelligent
health system. It’s absolutely imperative that we embrace this new model of
care which is centered upon the individual in order to save lives and save
money for all Americans.

So, I believe that the patient-centered primary care collaborative really
sets the stage front and center and models the way for the public policy
discussions in particular and the decisions that are needed for widespread
adoption of the patient-centered medical home. Central to the patient-centered
medical home is the premise that this type of care requires a fundamental shift
between our patients and their primary care physicians.

There needs to be a higher level of personalized care coordination, which is
beyond acute care episodes and the identification of the key medical and
community resources that would meet each patient’s needs. The widespread
adoption of the information technology for care management and quality
improvement, along with adequate payment methods is essential.

So, large employers have been successful in challenging health policy
conventions in the past. A couple of key examples that come to mind are Leap
Strong and Bridges to Excellence, where these were really grassroots uprisings
that were led by employers and have really gotten a lot of traction in the US
as far as healthcare reform.

I guess to kind of bring things back full circle and summarize these points,
IBM is a large employer. It’s a major purchaser of healthcare in the U.S. and
we spend quite a bit of money to provide healthcare choices for our employees
and their families. We are not satisfied with the current focus of our
healthcare system that is on episodic acute care instead of comprehensive
coordinated healthcare promotion and disease prevention. And we’re also
dissatisfied with the quality of care that is currently available.

The patient-centered medical home is a healthcare model that we really would
like to buy for our employees to improve the aspects of cost, quality, and
access. We’re helping to make a difference in the delivery of healthcare by
advancing the need for greater adoption and implementation of the
patient-centered medical home.

And there is certainly great opportunity for other large employers and
stakeholders to come to the table under the umbrella of the Patient-Centered
Primary Care Collaborative to make the patient-centered medical home a
widespread reality. So, thank you very much.

DR. STEINWACHS: Chris, thank you. I want to apologize. I forgot to introduce
you. You introduced yourself, Mr. Chris Nohrden. I appreciate that. The third
on the list is John to come back in another role here.

DR. TOOKER: You’ve already heard a lot and there will be some redundancy
here. I’ll move through these slides so that we have time for questions. James
and Chris have keyed this up very well. And I’ve heard Susan many times and
she’s a very articulate spokesperson for the team.

So, the question we have all been asking ourselves is there a better way to
organize, coordinate and finance primary and principle care that would lead to
better outcomes, more cost and increased interest in primary care. That has
been the policy driver at ACP and I think it is fair to say for all of us now.

I want to re-emphasize again in the cases of the key medical home actors
that there are strong pieces of primary care model that have been incorporated
into the patient-centered medical home. And I really to give credit to the
primary care, the Institute of Medicine, and in particular to Barbara
Starfield, who I understand will be one of your discussants tomorrow.

Barbara is legendary in primary care, and she has been extremely useful in
the sense of can we, at this point really measure within the patient-centered
medical home whether all of the tributes of primary care are being fulfilled in
that home.

And lots of conversations, I want to emphasize for the panel today, that we
are at the patient-centered medical home version one, and this will evolve over
time. And it won’t be until we have been able to test it in models such as
James mentioned about a research model that we’ll be able to refine it. But, I
think it’s key to remember all of these three models of care are now being
incorporated.

So, in terms of the key patient-centered medical home actors, I think it’s
important to step back and think about that we have to start from the pipeline
of the beginning medical student all the way through a point where mature
physicians are retiring from practice and try to figure out how we are going to
be sure that we are addressing in primary care each one of those pieces now.

I think it’s really important for those who are particularly concerned about
primary care to know that there has been a remarkable fall off and interest in
primary care in the last six or seven years. And I mean remarkable. When I
talked about the collapse of primary care, in lots of medical centers now,
medical schools, less than five percent in some cases, none, of graduating
medical students are going into primary care, other than pediatrics now.

The challenges of course are that it takes a long time to restore that
pipeline to the point where you have a predictable throughput through the
system to be able to provide the workforce that we need. In terms of key actors
and training for medical and graduate medical education, they are the AAMC, the
Association of American Medical Centers. And a year ago, we petitioned the AAMC
to take a position on the patient-centered medical home. And to their credit,
they have.

In April, they published a position paper on the patient-centered medical
home, which has some key features that are appealing to us. One is that they
have agreed that there is imperative to train and incentivize physicians to
enter primary care and to train them appropriately.

And this is a challenge in academic medical centers because of this tension
between the provision under our current payment system of high volume very
expensive services, which are reimbursed much much higher than primary care is
and to incentivize so that you are training primary care physicians.

There’s the Society of General Internal Medicine, there are the academic
societies within family medicine and pediatrics, and the American Osteopathic
Association, and one more that is important here –- I just met with them
two days ago after this slide was produced –- is the Association of
Academic Health Centers.

They are taking a longer position, not just in physician manpower or person
power I should say, workforce, but rather, they are taking a point of view of a
soon to be released position paper on other medical providers, including those
who are part of the team of patient-centered medical care.

Now, you are going to hear a lot more from Terry and others about CME and
practice transformation, but it’s the professional medical societies that
historically have the role of continuing medical education, much more so than
academic medical centers now. And in this case, we are not talking so much
about traditional CME that is the medical education around the improvement of
clinical care, but in practice transformation.

How do you change your practice so that it is able to perform as a
patient-centered medical home? And you’ll hear much more about that.
Collaborative, you’ve already heard about. And there are smaller entities as
well. It’s important to know that we don’t have the expertise to all of this
work and have contracted with consultants -and I know that Mathmatica is here –
Mathmatica and the Urban Institute, to help us understand what the
patient-centered medical home means. That if we do a pilot of demonstration
projects, these must be scientifically rigorous pilots so that we have
objective third party information about these pilots that is useful, both in
terms of scaling to larger entities, but also to be able to publish our work in
peer reviewed publications so that it will stand the test.

And then there are foundations, and I’m only touching the surface here, but
the Commonwealth Fund has been extremely helpful about obtaining data in
support of the patient-centered medical home. Robert Wood Johnson has also been
important. They funded the work of the McCall Institute to develop the chronic
care model. And we’ve already heard from James and also from Lee, about the
critical importance of the federal and state government. And I want to point
out the leadership that the states, including Medicaid, have provided. In some
states now, there is legislation requiring the implementation of a
patient-centered medical home. Washington State is a recent example.

Some have gone ahead and implemented because they see the benefit of the
model and are able to do so. Tomorrow, you’re going to hear from Jim Walker at
Geisinger and Geisinger is a remarkable health system in central Pennsylvania
that has already implemented patient-centered medical home and have done so
successfully.

There are always innovating smaller private practices that have done the
same thing. We want to learn from them the challenges having data from these
experiences that we can use to test the overall model. Testing is occurring in
multiple pilots and demos. There are at least six relatively mature pilots and
demos at the state level right now, and James has mentioned the Medicare demo,
which we hope to go live – if I’m correct James – in early 2009?

MR. COAN: Yes. Cautiously.

DR. TOOKER: Thank you. I didn’t mean to put you on the spot, but you’ve
helped me a great deal. But, that’s what the target would be and critically
important as James said, was to figure out what the per member, per month is
likely to be. The care coordination fee depending on the maturity of the
medical home and the work of the rock(?) in doing so.

The policy implications are substantial and, as I indicated earlier, MEDPAC
and Congress are now much more involved. And I would say that I have heard a
“read my lips” all three presidential candidates mention the medical
home now. I don’t know if we’re talking about exactly the same medical home,
but I’ve been very less than careful to trumpet that I’ve heard it from all
three of their lips now.

And then the role of policy in the professional medical societies. I want to
point out in terms of the actors here, that this isn’t all kumbaya. There are
some real tensions in the medical community about the patient-centered medical
home because there are parts of the medical community who really like the
current payment model, and that is a volume based model, as Elliott Fisher
said, we have to uncouple the volume incentive from payment.

But, they are definitely out there now and because they are out there, we
are faced with the 10 percent reduction in Medicare payments as of July
1st because the volume targets have been exceeded now. So, those say
parts of our profession who benefit from doing more. Then we have to figure out
how to work with them in some sort of a shared model in which the incentives
are aligned to improve quality and to reduce cost.

Internal medicine. I think I would be less than candid if I didn’t say that
those tensions exist within our own subspecialties in internal medicine. And
then, what I think is really important and underappreciated is the role of
state legislators. State legislators have been more assertive, in my opinion,
then the Congress has been and moving faster because of their needs within
their states to provide healthcare to their citizens.

And with Greg here, I’m not going to say more about the qualification of the
medical home through NCQA. And you’ll hear probably tomorrow from Barbara about
how well the current PPCA model relative to patients at a medical home can
qualify a medical home. Are we really measuring the right things? And that’s an
important discussion for us to have.

Let me move on quickly to the stakeholders now. And by stakeholders, I’m
referring to those who are actively engaged in either providing care or
receiving care within the medical home, or a relationship between the two. And
I want to emphasize that we are talking about again the relationship with the
primary care model to the chronic care model to the patient centered medical
home. This is really about patients and families if we are talking about
patient-centered care.

And I give great credit to the pediatricians for thinking about the role of
families with regard to special needs children, but I also — and I was smiling
when Chris said that the average employee at IBM is approaching 42. That seems
quite young to me. As the Medicare population ages, it’s the rule of thumb that
once a man and twice a child – meaning that the families increasingly become
engaged as the family members age now. And that’s very difficult to do, to
engage the family around patients who are elderly as it takes a lot of work to
manage those relationships now.

So, if a patient voluntarily chooses a patient-centered medical home, the
patient is at the heart of that patient-centered medical home. They are on a
par with the team that is providing care. And the team can and will be
constructed relative to the local needs.

And one of the challenges that we have right now in talking about this at
the national level, realizing that all care is implemented locally. And there
are always a lot of local factors that relate to how care is practiced now.
Here are a few of the people who are the professions who might be part of the
team: Physicians, nurse practitioners, PAs, certified diabetes educators,
licensed social workers, et cetera. And with these small practices, it’s a
challenge because obviously a small practice can employ and not employ all of
the members of its team. So, we need to think about virtual relationships and
networks and where the expertise of these professionals is shared among
practices in a voluntary arrangement now.

As we mentioned, the role of the patient-centered medical home is not just
to provide a primary care and chronic care model, but also to provide
preventive care and acute care.

Now, one of the features of the Wagner Care Model is realization that
medical care occurs in the context of the community in which patients live,
again, the importance of the local relationships at the community level. So
that these patients need to move to and from. And I thought James said it
extremely well, that when you get to the Medicare populations, the number of
interactions that they have with healthcare systems is enormous.

And we may think they all have the same relationships, but you have to stop
and think, I do, that each patient has a different set of relationships within
the community. The point being it becomes exponential in terms of the number of
interactions going on within a community that have to be managed. So, these
patients will have a specialty and subspecialty care and we have to manage this
relationship and know that the arrows reflect a communication going both ways,
and that is one of the things that are most missing now. That the information
does not get in the hands of those you are referring patients to and does not
get back and leads to a huge duplication of services because the information is
not available at the point of care and these are very complex relationships.

My wife has had a set of serious illnesses, and when we get her hospital
bill after one of these hospitalizations, it is completely indecipherable from
the point of view of the patient. Fifty pages long, item by item by item and we
have to change that so patients understand the care that they are getting and
what they are being charged for that care and then this relationship to the
community.

I’m oftentimes asked what you think about the personal health record. Well,
it’s a good idea in concept, but when you see the number of interactions with
the community that a patient has over the course of the year, you realize how
devisly difficult it is to get all that information in the right way within a
patient-centered medical home personal health record so that the patients and
the practice have the same understanding of what that information is.

When you think you have it right on one day, the next day it is changed
again. So, I want us to be really thoughtful as you talk about the technology
tomorrow about not just the technology within the patient-centered medical
home, but how this relates to the information the patients have if they are
going to be activated patients now.

Now, a lot of patients may have a predominant illness. And for those
patients, they may choose a – and practices may choose – to have a
principle care or a specialized medical home. And that is wonderful because
patients should get care where they want it. But, if they view that their
cardiologist who’s managing their chronic congestive heart failure is the place
where they want to get their medical care, as long as that practice is willing
to provide the other services that the patient-centered medical home, they
should benefit from the payment relative to the work that they do, including
this important care coordination now.

So, this isn’t all about primary care. And I want to be sure that we
understand that there are going to be multiple models of the patient-centered
medical home. Not just the primary care model. So, I will stop with that, and
I, along with our colleagues, are open to any questions you might have.

DR. STEINWACHS: John, thank you very much. Lee, I’ll just ask you if there
is anything you wanted to say. Okay. Well, this has really been very useful in
talking about the perspectives of payers, employers who have dual roles, and
John, you have really walked us through very nicely the key actors and the
stakeholders so I’d like to open it up to questions and comments.

DR. FRANCIS: This goes back to some of the points Lee made. First of all, I
wasn’t clear when you describe the demonstration project as voluntary, whether
that was going to be voluntary on the part of the physician or also of the
individual patients within the practice. So, that’s the first question.

But then, related to that, what are the reasons that people didn’t like
gatekeepers was that they sometimes liked to shop around if they were unhappy
with the care that they were getting. And not to have their first physician
know everything that they’d done. I mean, I’m on the privacy subcommittee so
this isn’t entirely out of –

DR. STEINWACHS: It’s good you’re asking these questions, Leslie.

DR. FRANCIS: I haven’t heard the word privacy and I read the documents that
were sent out ahead of time and I didn’t see the word privacy anywhere, but I’m
just curious about the question of whether there has been any thought given to
information flow from the perspective of the patients. So, if a patient with a
medical home went somewhere else and didn’t want the medical home to know about
it for whatever reason, good or bad, and I’m not necessarily saying this is a
good thing, how is that being conceptualized? Maybe this isn’t the time to ask
it, but that’s—

DR. STEINWACHS: The first question, I think was to Jim about what voluntary
meant, and then we can come to the security question.

MR. COAN: Participation in our demonstration will be voluntary at all
levels. The physician practice will choose to participate or not because there
is a certain investment in time and effort to become recognized to fulfill the
qualifications. Patients will also be invited by the practice to participate.
They do not have to and their care will not change as a result of their choice
one way or another.

DR. BREEN: Well, won’t they get the medical home. I mean, that’s an
intervention, isn’t it? Medical home?

MR. COAN: Yes, only to those that would be eligible because of what the
legislation tells us. In our case, it’s a fee-for-service demonstration. So, it
won’t apply to managed care Medicare Advantage patients. The main reason for
that is we don’t have any data from Medicare Advantage that we could look at
for claims purposes to determine whether or not there is any recurring savings
as a result of doing the medical home. So, it’s not that we don’t like Medicare
Advantage patients.

The other criteria come from the legislation about having a chronic illness.
So, we have to apply that into the demonstration. Basically, a Medicare
beneficiary who has both Part A and Part B, but does not have a chronic illness
would not be eligible to participate in our demonstration.

DR. FRANCIS: I’m just curious about the thought of information flow.

DR. STEINWACHS: Lee, about the privacy?

MS. PARTRIDGE: You’re right about the privacy issue. IT has come up in our
early discussions. I think perhaps it might be a little less relevant to the
Medicare community than it is to some of the younger people. Christine will
probably touch on this or may think about this in connection with teens in
particular. You may not want – it’s pretty obvious, I think.

Where you strike this balance is very difficult. I think ideally, the
medical home environment would be such that you would feel comfortable sharing
everything. From the perspective of the clinician, that’s certainly desirable.
I don’t know how you get there and people are certainly going to be very wary.

DR. PAWLSON: A couple of things. One is we’re actually looking at trying to
build in some communications with the patient about medical home and its
properties from the practice itself as part of the basic sort of qualification
medical home. Secondly, I think in thinking about this, patients would be
– there would have to be some kind of opt-in, opt-out. I’m not talking
about the Medicare demonstration because that’s something that Jim and his
group will be looking at how exactly that’s going to be handled, but it is
voluntary. It’s not a gatekeeper model. You’re not forced into it by your
health plan. It’s a free choice and hopefully, there will be sort of a contract
between the practice and the patient saying that I acknowledge you as my
medical home. I want you to have information to coordinate my care. But, the
flow of information and the information system itself will still have all the
safeguards or not that are inherently there. I don’t’ think that this will
particular change it, other than hopefully illustrating to the person that
chooses a particular practice as their medical home how important the
communications are and if they choose to withhold it, what that means or
doesn’t mean in terms of their actually having a medical home.

If I don’t have information on half the things going on with my patient,
it’s not going to be much of a home.

DR. STEINWACHS: I have Harry, then Larry, and Justine on the list.

DR. GREEN: I wanted to go back to the Medicare demonstrations with a
question about both methods and metrics. What is your current thinking about
what measures are that you are particularly interested in? Is that publicly
listed and does everyone know what those are? Is that part of the details that
we should wait for? And the other one is what is your thinking – well, let
me frame the second question just a little bit.

I like research, okay. Guilty as charged. I like stronger methods versus
weaker methods. But, I’m also interested in timeliness. And when I look at the
needs for getting on with this, waiting for classical randomized control trials
to get delimitative very strong methods answers to some of these things makes
me think that by the time we get the answers, it will already be decided by
other methods and other means.

So, are you thinking about moving to approaches to evaluate different
strategies for the medical home, getting mix performance characteristics
figured out through methods other than randomized trials, or is the plan that
you can’t randomize. It’s not strong enough. We’re not going to play forward.
We’re not going to do it. What’s your thinking about both the metrics and the
methods?

MR. COAN: Both good questions. I’m afraid I’m going to sound like I’m
copping out on you a little bit. Your first question has a lot to do with how
the evaluation of the demonstration will be designed, and it hasn’t been
designed yet. So, there are concepts at this point. I think it’s safe to say
though that Medicare is going to be looking very hard at where do the savings
come from. The idea in this demonstration is that it be cost neutral. So, that
whatever the fees that are paid for the medical home services, which are,
incidentally, they’re in addition to the usual ENM services that would be
covered. So, a doctor could still submit a claim for service that they provide.
Medical home fees would be in addition to that.

But, those fees should be offset by savings, probably at the Part A level –
at the hospital emergency room or the avoidable hospitalization level. We will
be looking at that. Other measures are being considered. They just haven’t been
brought in at this point.

In terms of the timeliness, in as much as everyone is interested in getting
some kind of bottom line results from things. There are some things that you
simply can’t rush. Not so much is known about medical home and how it’s set up.
There are pilots. There are demonstrations going on and they are very good, but
there are also a lot of differences. However, subtle they might be in their
application.

We have to be careful to design a demonstration that first of all fits the
legislative language that we use and also put something practical on the
street. It’s real world to us, it’s not theoretical. When we put it out for
demonstration purposes, this is how we think it might actually look in the end.
Something very close to it, but it has to be something that is replicable. We
can’t create a demonstration that you can’t use throughout the country. I find
some very good results, but you can’t replicate it anyplace.

So, in terms of the timeliness, it’s not something that we’re included to
want to rush to get it resolved. And whether or not there will be conclusions
before we are through doing what we have to do, we’ll have to wait and see.

DR. STEINWACHS: Okay. Thank you. Harry?

MR. REYNOLDS: I appreciate all the testimony, and as we listen today and
tomorrow, I’m anxious. I just went through a lengthy illness with a family
member, much like you mentioned. And watching a specialist come in and each day
for 45 seconds a day at a time and not be coordinated is an issue.

But, on the other hand, to think of a primary doctor that would be
coordinating all that information also added a significant burden to them quite
dramatically. So, any comments on that because that seems to be under normal
process, a normal information flow right now. I just don’t see how that works.
This is changing so fast daily that they are trying to coordinate it with
different – the other thing is I keep hearing voluntary, but when there is
a payment, voluntary only goes as far as where the voluntary stays together.

So, if a patient signs up to be a voluntary member of a medical home and
then decides to go out and get four other services outside the medical home,
which means they are immediately not coordinated and if the primary care doctor
says things are great today, but I don’t think you should go do that other
thing, then it started to feel and act a whole lot like a gatekeeper. So, if
anybody can help with what you’ve seen so far how that plays in the real world
because this committee has done a lot on seven minute doctor visits and all
this other. And then you’re thinking e-visits. And if you know anybody who uses
a lot of e-mail, e-visits could be the goldmine for them if they’re going to be
checking with a doctor every 10 minutes.

So, all this stuff wrapped together when you’re trying to think about how
all this works is what’s going to be really interesting to listen to. So, if
anybody can make a comment now. But, all these things individually sound good,
but when you put them together, I’m still struggling with exact process and how
it works.

DR. TOOKER: Maybe I can start it, but I want to emphasize that this is a
system of care. And probably hard to overstate how important a system of care
is. We’re so used to these episodic episodes of care in which they’re patients
who are not in a system of care. The model is one that is a model of trust in
which patients say that if you look at Commonwealth data, they are there.
Patients want a personal physician in a medical home.

Now, understandably, no model is perfect and there will be patients who say,
I don’t know. I need to go see my cardiologist. But, if the model works and as
a model of trust, patients will be informed and activated and will be
participating in their care. And they will develop just as they do now, a
relationship to their practice, and if they trust the practice, then at least
they’ll say don’t you think I ought to go do this, as opposed to not telling
their practice that they are seeing other physicians.

The reason that people are doing this is a failure of our current system of
care. In order to have a patient-centered model such as Chris was talking about
that is well established in other countries, these are places that patients
trust. And if they don’t trust it, then the model is not working.

In order to be activated, the patients need to understand that if they
choose not to tell their primary care practice about other care that they are
receiving that they are putting themselves at risk because when it comes time
to inform the emergency room about what the conditions are and what medications
they are on and by the way, medication reconciliation is one of the most
important issues n all of this right now and leacs to considerable harm and
expense and the model isn’t working. So, as indicated, we’re at version one and
we need to test it to see what really happens to patients. Fortunately,
patients being paid under Medicare, if they are choosing to seek services
elsewhere and those services are being billed for, you can detect when they are
receiving services elsewhere.

I want to emphasize what I meant by the word voluntary. One is that
practices can voluntarily decide if they want to be a medical home or not. And
as you pointed out, this is complex, hard work, but a fully trained family
physician, internist, or pediatrician operating at their level of competence
and license is very capable of running a medical home.

The next piece of that is that there is sense that the doctor has to
understand and manage all of this. The doctor is responsible for overseeing the
team. And when you get into care management, you are delegating this
responsibility to other team members to do the care management that you are
responsible for. You don’t have to know every detail about every patient in
your practice as long as you are measuring your practice and delegating
responsibility to those who are also fully qualified to do it.

Second is that the home is voluntary to patients. Now, I agree we may get to
a point where particularly with those who are paying the bill saying we want
this to be less voluntary if we are going to fully participate, but we’ve
learned the hard political lesson with the gatekeeper model that if you tell
patients that they are forced into this decision, they are going to find a way
out of it now and it erodes the trust factor in the patient-centered medical
home. So, patients that need to know that it’s voluntary.

The second feature of it being voluntary is to say you’re in a community
that is fortunate enough to have more than one political home; patients have a
right to choose which medical home they think is best for them based on the
evidence that’s available. So, to me, these are very testable hypothesis to see
whether or not this is going to work and is part of testing the model to see
whether or not it does work.

DR. STEINWACHS: Greg?

DR. PAWLSON: A quick addition to that. Pardon me for using a sports analogy
here, but I think our current healthcare sector is like paying a basketball
team. Very good basketball players, the best you can find to shoot at the
basket. Not to make baskets, not to play defense, which I would sort of look at
–playing defense is like preventative care, trying to prevent things from
happening. And then we wonder why the system isn’t working.

I had an experience with my mother very much like maybe you’re describing
with 14 weeks in ICU and her eventual death. And it was really remarkable how
many people managed to make a lot of money off that. I think her total hospital
bill was close to $400,000. And doctor bill pretty much the same. Yet, nobody
in that whole thing was paid to kind of sit with us and try to figure out what
the heck was going on.

And I think this has to happen in the hospital for the patient as well as in
the outpatient environment if it’s going to really be successful. If you just
take an international example, or within the United States, look at the
difference in cost and quality between the upper Midwest, Minnesota, Wisconsin
and Miami, or the United States and Denmark.

And when you really get into those, what is the difference in those things.
What do you have in Miami is small aggregated practices that are all mostly
fee-for-service. And everybody is just full out shooting the basket every
chance they get. Whereas, in Minnesota –- I don’t know whether it’s the
long winters or what it is, but there’s a collaborative model that is much
longer there. I think some of it is the influence of the health plans or some
of it is large medical groups, but there’s a pervasiveness of much more
coordination of care, much more focus on primary care. So, it doesn’t have to
be. We’ve gotten used to it and then we pay for it that way and we wonder why
it keeps going.

DR. STEINWACHS: Maybe we have to pay people to be part of a team too. Next,
I have Justine and then Nancy.

DR. CARR: I have a question about whether there are lessons learned from
concierge medicine. I’m from Boston and a number of years ago, probably three
of our premier internist groups opted to become concierge medicine. And for a
few thousand dollars, patients could sign up and they reduced their panel size.
And I think many of the concepts of the patient care home were achieved by
having more availability.

It wasn’t as much of a team. Although, in some ways it was, but the other
part that was interesting is that patients clearly opted in because they were
the ones that were paying the annual fee. I’m just wondering whether there have
been any looks at concierge medicine practices such as this and any
observations that could align with the medical home?

DR. TOOKER: Very good question. There are lessons to be learned from the
Concierge model which patients pay an upfront fee A) to be able to receive the
kind of services that we’re talking about, such as availability 24 hours a day,
seven days a week. And it is a form of a per member, per month payment to
guarantee those services the patients desire.

I think on the patient care side that you will find increased satisfaction
of patients. The challenges of course are as a scaleable national model, that
one, this is not voluntary in the sense that the practice decides who they want
in their practice and who they don’t want in their practice and exclude
patients from their practice that they don’t think are the right patients for
their practice. And it can be because of the complexity and the severity of
illness. It can be because of the affordability of the concierge fee for the
practice. And it then pushes those patients to other sources of care in the
community such as community health centers if patients can’t afford it.

I don’t think it’s a scalable model. In order for us to get all patients in
which they are not differentiated on the ability to pay. Our sense of the
medical home model is that every patient, including those who are uninsured
ought to have the same access to care as any other patient. So, how to take
care of patients and learn how to manage.

So, I think we can learn how to take a certain amount of money and manage
patients well from that. That would probably be the primary lesson learned and
what does that generate in terms of patient satisfaction. I don’t really mean
patient satisfaction, but the ability to measure patient experiences of care.
Now, that’s probably something to be learned, but I think we have trouble with
exclusion of patients on the ability to pay.

DR. CARR: I just want to be really clear. I wasn’t proposing that as a
model, but simply to move forward on the idea of outcomes and satisfaction.

DR. STEINWACHS: Okay, Nancy, you get the last question before break here.
We’re running a little bit behind.

DR. BREEN: Okay. I had a couple of detailed questions for James, Dr. Coan,
at CMS, and a question again, for Dr. Tooker. When you were talking about the
research that you’re going to do, the medical home intervention, you did say
that you got 12 people around the table and they came to an agreement. And I
was curious just in the ballpark approximately what does this seem like it’s
going to cost?

MR. COAN: It’s an excellent question. I have to say for the record, I’m not
a doctor, but the committee keeps on trying to give me the credential. I’ve had
to fix that a couple of times. Thank you for paying the compliment anyway. As
far as the question, we haven’t done the calculations of the RVUs. It has to be
done within the Medicare concept. One of our divisions actually puts the
amounts together.

So, it’s not as easy as looking at the values and saying, oh that’s a 2.8 or
that’s a .4 or something like that. And simply saying, oh that calculates out
to about $1500 a patient. It doesn’t work that way. And we haven’t had those
calculations run out yet. So, I can’t answer your question.

DR. BREEN: Okay. And the second thing was about patient involvement. I’m
cuprous about that because there’s quite a lot of literature, especially in the
cancer literature, which I would be more familiar with about the extent to
which patients wish to be involved. And then whether patients want to be
informed in their decision-making, or whether patients want to actually
collaborate in their decision-making.

And these are multiple concepts that are out there in the literature now.
And I wondered -– you said, encourages patient involvement in their own
care -– is this something you’ve thought about much for this project in
terms of how you’re going to –- what standards you’re going to set?

MR. COAN: I think what we’re talking about here, and I’ll refer to Dr.
Tooker’s comments – it’s a system of care. Therefore, that would be
available to the patient as a service. It would be up to the patient as to
whether or not they would want to utilize it or not.

They want to be actively participating in their care or they want to be
secondarily interested or active in their care. Again, it’s not a mandatory
thing for them, but the medical home must have the capability I think from our
point of view to provide the patient education, the materials and also the
reinforcement should they want to become interested and active in their own
self-care.

DR. BREEN: Mr. Coan, I’m starting to worry about how many arms are going to
be in your experiment – different variations that are going to be tested.

MR. COAN: Again, we’re looking at the system of care. The medical home is
going to have to qualify. It will be recognized as having certain core
capabilities, which the practice becomes recognized for that purpose. Core
capabilities and the practice permit the personal physician that the patient
responds to directly. The core capabilities allow that personal physician to
provide that level of care to the patient. So, again, it’s a systematic sort of
a thing.

What we’ll be looking for primarily from our point of view are the outcomes.
Our endpoints will certainly have a financial aspect of it. It might have some
kind of a clinical aspect of it, and we’ll certainly have a quality aspect of
it as well. But, I don’t think we’ll be looking at it in terms of did this
patient participate in their own care.

DR. BREEN: So, the protocol will be not maybe too specified. It’ll be more
if you have this situation and it can be delivered in many different ways.

MR. COAN: Yes. I think you just hit the nail on the head in that
circumstance.

DR. BREEN: I hope you’ll document how it is delivered though. I think
that’ll be an important part of the research

MR. COAN: If it’s possible to do that. I’m not so sure.

DR. BREEN: And then I was going to ask—

DR. STEINWACHS: Is it very short?

DR. BREEN: Well, it’s a short question and maybe you can keep it short. I
was just going to ask what value added you were gong to do because there is an
experiment already going on at CMS on medical homes and what other research
questions did you want to address or what did you want to find out with the
research that you alluded to in your talk?

DR. TOOKER: The pilots that are going on in the private sector and the
public-private partnerships are all different. In the pilots that we started
initially, among the research is that if we pick an arbitrary payment of per
member per month – by per member I mean the plan in the panel patients
that the physician has, is that payment the right amount? Is it too little, the
right amount, or too much? And we really don’t know the answers to those
questions. We would like to be able to measure the impact of changes in
patients over the course of the period in question. Patients are not static. At
the time that you measure what the severity of illness is, six months later, it
may have changed. It may have change for the better. IT may have changed for
the worse. So, how do you institute a flexibility within a per member per month
to be able t not to manage absolute risk because I want to emphasize at the
outset that this is not a strict capitation model. As we just cannot afford to
let these small practices fail in this experiment that we’ve asked them to be a
part of.

A key part of this that we want to measure is how do you estimate the
balance between the traditional sources of practice revenue, fee for service
and the amount of care coordination to achieve a desired outcome. We talked
about the ability of patients to engage in their care, we know very little that
if you fully engage them, what the impact of that engagement is on their care.
And that includes improvement in the quality, but it also means reductions in
costs because the less able the patients are able to control their conditions
on their own outside of the face to face visits, the more expensive that care
is going to be because they are likely going to show up in emergency rooms and
other places where care is going to be more expensive.

It’s one thing to be able to engage with a patient at the point of care. We
have to realize that 99 and nine-tenths percent of the time, patients are not
in front of you. They are out where they live and they have to manage their own
care from day to day. And those who are very knowledgeable about a serious
complex disease realize that everyday there are questions about your disease.
And you can’t just pick up 1-800 and get the answer to those all the time. You
have to learn how to do this. And I’d encourage us to think about an article
that Frank Davidoff, who is a former editor of the Annals of Internal
Medicine, wrote an article about not how sick people are, but how hard, how
much work it is to be sick. And once you get into this realm of severe chronic
illness, it is relentless. You can’t take a day off everyday. So, how to
activate these patients and empower them to be able to feel more responsible
and that their illness is more responsive to their interventions rather than
relying on the practice all the time is an area that we know almost nothing
about. This is unchartered territory for us.

DR. STEINWACHS: John, thank you. I’m going to leave people with that idea of
no day off and we are going to break until 3:15. That’s about 10 minutes. I’m
giving you a little bit of time off because we have to keep going and I want to
thank all the speakers for the first two sessions. It’s really been very good
in setting the stage and we’ll move on to measurement issues next. Thank you.

(Break)

DR. STEINWACHS: It’s really a great opportunity to get at the measurement
question and what’s being done currently. Dr. Greg Pawlson will be talking
about the NCQA measurement process for qualification. I’ve now learned the
difference between qualification and certification. I’ll try and not make this
mistake again. Harry could have explained it to me too I know.

And this will be followed by Dr. Christina Bethell talking about measurement
in the case of the medical home for children with special needs, which is
really sort of the beginning of the medical home concept was really focused on
this. And the kinds of data that she has been developing at state level and for
national state policy purposes.

So, what I’m hoping, we’re going to keep the 45 minute time allotment that
each of you will be talking in the 10 to 15 minute range at most because as you
can see, there are lots of questions and interest from this group and I want to
really be able to tap into your expertise. Greg, please proceed.

Agenda Item: Assessment of the existence of PCMH – What We
Should Measure and How Currently

DR. PAWLSON: This has been probably the biggest measurement challenge I’ve
certainly seen since I’ve been at NCQA because it’s sort of like the blind man
and the elephant. Everybody’s got their perspective on what the medical home
should look like and to come up with a set of metrics for an animal that nobody
can see except by probing a stick at them has been a major challenge.

So, what I’m going to talk about is how will we know one when we see it and
how will we know if it enhances value. This is a very very busy slide, but it’s
kind of an attempt to pull all of this together and to look at how on the left
hand slide individual clinician staff’s attitudes and behaviors are going to be
important for creating the key –- and that’s in the orange –- patient
centered ongoing care and how office practice systems are also critically
important in that. How that comes together. The boards will do evaluation and
the boards have actually adopted some of the same metrics that we’re using on
the practice side. Evaluate individual clinician attitudes and knowledge about
systems. And then how do we evaluate the patient centered medical home? And
there are really sort of two branches here.

One is the qualification or the basic characteristics we think ought to be
there before you call something a patient-centered medical home, but then
there’s the question of what does it do and how do you actually evaluate the
impact of the patient-centered medical home. And for that, you need two major
pierces. One is clinical process and outcome measures, including resource use
measures, I do believe, at least at a systems level, not at an individual
practice level, but looking at systems that use the medical home as a basis
versus systems that don’t. There should be a difference in overall resource use
there.

We should be able to find a way to measure that. There should also be
certainly clinical quality measures that show a difference. And indeed, we’ve
seen at least on a cross-sectional study, differences in practices that score
high on the PCP instrument that I’ll talk about do have higher aggregate
quality scores and diabetes and cardiovascular disease as of right now. And
then very very importantly, and some will argue this ought to be part of the
basic qualification of the patient-centered medical home is the patient
experiences a care tool.

And this is the clinician group capped. We think that it should perhaps be
modified and enriched with patient-centeredness kinds of questions. It has some
clearly, but there are probably an additional set of questions that ought to be
considered for use in the clinician group cap survey, either as part of the
qualification of the practice. So you’d actually have to pass a certain level
of patient experiences of peer performance or certainly in the evaluation. So,
you should see an impact on patient experience of care. You should see an
impact on cost. You should see an impact on quality. Both in terms of usual
clinical quality as well as some overuse and misuse kinds of measures.

This sort of turns what I just said, into sort of an outline in terms of
words. The evaluation of the impact of the PCC I’ve also sort intimated. And
this just goes into a little more detail of what kinds of measures might be
available to look at the impact of the patient-centered medical home itself
beyond the qualification.

This is a way of just conceptualizing the linkage that John pointed out. The
medical home model will not work if we don’t change the reimbursement system.
Period. End of story. It just isn’t going anywhere. And I might add this is
what’s used in Great Britain. And I think it creates what you really want to do
is -– and I’m a little bit hesitant to say this. I think there’s an
economist in the room – but it’s a balance payment system that really
encourages the clinician to do what they should do for the patient. Not have
entered into that either the negatives of either capitation, pure capitation,
pure salary or pure pay for performance or what we have now is pure fee for
service in terms of motivations that might, in some cases, overcome what he
patient really needs. The qualification tool that we’ve developed is called the
physician practice connection. It’s an attempt to create what we hope is a
reliable valid and scalable instrument that can be used at the indivdiual’s
site level.

The site can be anything from a single solo practitioner’s site, and
includes everybody in that site. So, if they have an office practice nurse and
an educator or something like that for some reason, that’s site. But it can
also include sites that have 50 or 100 physicians.

It’s a geographic site with a single medical record. So, it has to have
that. In many offices here in Washington D.C., there are eight physicians
practicing together in a building and they each have their own medical records.
That’s not a site. And that they have some personnel policies in terms of their
clinical practice that are the same. So, it really requires those things.

It was developed and tested over the last seven years and we’ve published
about five papers now looking at the reliability and validity of the
instrument, and it’s sort of some basic stuff like do people understand when
you ask them do you have a registry, do they know whether they have it not.

And we found out that they don’t. But, we’ve actually incorporated into the
instrument a requirement that the practice actually –- and there’s a whole
bunch of options that the practice can use -– actually demonstrate through
attached evidence. They can actually attach right to the instrument whether
they have an instrument or not. So, it could be a screenshot, for example, of
the registry with the patients’ names blanked out.

The tools have been in fairly widespread use already in the Bridges to
Excellent program that GE fostered. And it was really based and focused around
the chronic care model and gauged the extent to which practices had
implemented, not just structured, but actually used the chronic care model. So,
rather than saying do you measure quality, it goes on and looks at how the
practice actually uses the measurement of quality in terms of feeding it back
and using it to improve their systems.

It goes beyond sort of handing out patient education materials to how the
patients are engaged in using them. So, it tries to get at use, not just
structure. Although, basically, one can term them mostly structure or
administrative process measures. In formulating the revised version that is
being used in the patient-centered medical home, and we sat down with the four
physician groups, plus we have a grant from Commonwealth to sort of revitalize
some of the old paper data on patient centeredness and sort of also take the
IOM definition and try to come up with tools that measure that. And what we
came up with were sort of two things that we think measured patient
centeredness. One is the physician practice connection modification that we’ve
done. And the second is some modifications to the questions that are in the
patient experience survey.

So, the tools that have come out of this thing, include not only the
physician practice connection survey used in the practices, but also some
changes we hope to the clinician group cap survey. These are the four, and
actually a fifth foundational area is primary care. The first contact
coordination continuity comprehensive chronic care model and the elements of
the chronic care model. What we’ve come to define as patient centeredness from
the study of the Picker Institute and other formulations of patient
centeredness. Cultural competency we’re trying to build into this. And then the
core medical home stuff that came out of the pediatrics literature in terms of
their focus around this.

There is clearly overlap in some of these, but there are areas that thee is
no overlap. So, we’ve tried to create again a tool that’s in evolution that
captures as much of all this as we can in this practice just in site tool. And
then where we feel we can’t measure that at the systems site level, lead it
into a patient experience survey because there are some things that a patient
can tell you whether they are experiencing it or not that you really can’t
measure anything close to reliably and objectively in the act itself.

This is a slide that you can read a little bit better on the hand out, but
it basically shows how we’ve developed this into nine different areas or what
we call standards. There’s about 15-20 elements in each of these standards that
are trying to sort of find measurable traits in a practice.

Measurable in a reliable and valid way that characterize whether or not all
the previous formulations and systems are present or not. It’s an evolution.
We’ve relied a lot on some stuff that Ed Wagner has done. There’s like 250
published articles on the Wagner chronic care model, including some randomized
control trials.

The buttress, the different pieces of the chronic care model. As I’ve said,
we’ve done some cross-sectional studies correlating the scores on this
instrument to quality and we’re looking at cost right now in terms of how it
may or may not be related to total cost of care. It also is interestingly
related to the tool that Steve Shortell has used in group practices across the
country to look at, again, the systemness and that instrument has also been
correlated with higher quality in certain practices. And finally, this is a
very living document.

While we’ve tried to sort of create something that could be used this year,
we’re going to be testing 50 new elements related to this testing in some
projects this summer to see whether they perform better than some of the
existing elements. And as we get information back from having this instrument
used in a lot of pilot and demonstrations, they are just starting up right now.
We’ll be taking pieces probably out of it. Again, looking at how well different
concepts actually work and how well, if the pilot and demonstration projects
are appropriately evaluated, how these different elements relate to patient
experiences of care, clinical quality measures and resource use measures.
Because that’s ultimately what we want, a refined instrument that takes the
best out of each of the areas that we’ve talked about.

The way that it is used right now in Bridges to Excellence, and we’re
presuming in most of the demonstration projects, is that there are three
levels, actually a fourth level, which is not qualified yet. Some programs are
actually going to use that not qualified level as a starting point so that any
practice that sort of attempt to engage in this will be included in the
demonstration and perhaps in the first year’s reimbursement. But, as you grade
the reimbursement on a member per month level, higher for the higher levels of
practice you will hopefully be encouraging practices to all move up the scale.

It isn’t a tournament model. It’s everybody can theoretically get to the
finish line.

So, in summary, and I’ve provided a whole bunch of slides that describe our
work on this and prior research and stuff in the appendices so you can look at
them at your leisure or ask questions about them in the question and answer
period.

What we think we’ve come up with is that the primary care patient-centered
medical home is the cornerstone to what we think is a true creation of the
health system. Measurements critical for guiding us because it’s an improvement
process and if you can’t measure what you’re doing, it’s awfully hard to know
when you’re doing it better. We realized the measures are going to be
imperfect. There’s a strong disagreement between Barbara Starfield and us at
this point.

And I think it’s very understandable. Barbara came at this form an almost
pure lens of primary care and her research suggests that just having primary
care in place, regardless of what sort of some of the systems characteristics
of the primary cares does improve care and we agree.

However, we think that these other elements of the chronic care model,
patient-centeredness and so on, are just as important as the primary care base
in actually getting U.S. systems perhaps to leapfrog or catch up with in some
cases like Denmark, catch up with things that if you don’t have a registry and
you can’t tell who your patients are, who are not doing well with diabetes,
it’s awfully hard to give really superb primary care. And that’s sort of where
would differ.

And again, we have a start of I think measuring both how to qualify these
practices, as well as how do we evaluate the impact, but it’s only a beginning.
And we’ve got a long way to go before I think any of us are going to be
comfortable with saying that we have a set of tools that really ferrets out the
most important aspects of the patient-centered medical home.

DR. STEINWACHS: Greg, thank you very much. Christina.

DR. BETHELL: So, thank you for inviting me here. And I think it’s great
because what I love about medical home is that it really brings up all the
issues of the structural and financing and cultural aspects of health care in
America. So, you get it all at one time. So, it’s very reach, but it also makes
it very difficult to talk about. Especially when you talk about measurements,
which is a very concrete thing and we’re talking about really a model of care.
So, let’s wish us all look.

What I’m going to do today is focus on measurement work that’s been gong on
for about the last 10 years on medical home for children and adolescents, both
children with special healthcare needs and without. And I think it has
application though. I know it has application. In my previous life, I used to
work mostly on adult healthcare and adult chronic illness and care models
around adults. So, I know there is a lot of synergy here. So hopefully, we can
build off of that.

So, my goals are to briefly give you some background on this research so
that you can have it as a resource and go back to it because I’m not going to
be able to give you a lot of detail today, although if you ask questions, I
hopefully will. And then to review quickly three tools that are in the field
now to measure medical home for all children and children with ongoing health
conditions for which they require above routine healthcare services, which is
the definition I’m using for special healthcare.

I’ll give you some current numbers. What do we actually know? We actually
have data and I’ll give you a resource you can look at to your heart’s content
in your hotel room. Hopefully, you can go online and scan and find all kinds of
things about medical home and what we know about medical home in terms of the
data that we have nationally and across states by numerous subgroups of
children. And it is compelling.

There’s a huge amount of variation and it raises lots of questions about why
given standardized measurement and variation, you have something you can
actually maybe begin to explore. And then quickly touch on adequacy, which is
what I was asked to do about what are the issues we need to consider and
continue considering.

So, in terms of background, for about the last 9 to 10 years, I and a team
of many other people have been trying to look at how to develop tests and gain
consensus on uniform strategies and patient-centered strategies for measuring
the presence of the medical home. Especially at the federal state health plan,
and hopefully, we’ll get there provider level. I think we are closer than we
think because that kind of consistency at those different levels allows
conversation to happen.

When you have similar metrics being measured nationally and in states and at
the system level, you can actually talk about and compare and have some hope
that you might be comparing and having a conversation that can get you
somewhere.

So, the first chunk of research – and again, I’m just going to tell you
what was done – and the resources that you can refer back to and then
really go into the review of the measurements itself was done between 1999 and
20002 with the support of the David and Lucille Packard Foundation with some
supplemental funding from ARQH to take what was then a nascent child survey for
CAHPS that hadn’t yet been really fully developed and actually develop it
largely around this concept of medical home, but at the time, that wasn’t
something people were talking about.

So, it turned out that we actually did develop something that speaks to all
of that, but it was not necessarily viewed that way at the time. So, we can
retrofit and have written a paper that explicates how to retrofit the CAHPS
survey that was endorsed by NCQA and NQF as well. So, that’s the first chunk.

And the National Survey of Children’s Health, where we have two rounds, 2003
and 2007 coming out later this year. Both of which have an explicit set of
metrics around medical home that are scored together as an index and numerous
subcomponents. We did do a study to do a formal item reduction. We started with
113; went down to 49; and ended up with 13 items that were the most predictive
of the qualities that we would expect to see if a medical home were being
provided. And this was funded by the Maternal and Child Health Bureau, who
really has been the thought leader behind developing the medical home model
along with the American Academy of Pediatrics and have a number of state
implementation grants around medical home going on in the field. That could be
a whole ‘nother presentation for you today.

And then finally, the National Survey of Children with Special Healthcare
needs, which we also have two rounds of. The data is available online for you
to query, and I’m going to give you a little bookmark to tell you where to go
to find out about it.

And in 2001, the measure built off of what we did in the CAHPS Children with
Chronic Conditions Survey. And the 2005 version is similar, but it did orient a
little bit more to a systems model versus a primary care or personal doctor or
nurse model, which I will explicate further as being one of the primary choices
I think that needs to be made in measurement.

So, the background process was very typical of a measurement process,
starting with expert stakeholders, consumer focus groups and frameworks
definitions and so on, as well as criteria for measurement being the standard
relevant feasibility and scientific soundness. So, that is my quick tour
through the research, but I will leave you with just some key products.

There’s a submitters kit that ARHQ has a hold of that goes through the
detail of the development of the CAHPS Children with Chronic Conditions Survey.
We were one of the maiden voyages on letting external people actually
participate in developing CAHPS related measures. We have a number of medical
home focus group reports from consumers and families, as well as some
literature. And then we just have a manual coming out this week on medical home
measurements and how it was done, and the pros and cons and different ways to
do it.

And then finally, the data resource center for child and Adolescent Health,
which was funded by the Maternal and Child Health Bureau as a free resource for
people to access the data that they have created in the two national surveys.
And I am going to hand this out because I don’t have slides. So, I encourage
you to go online and you can click your way to the medical home measure pretty
quickly and start querying it by states, nations, subgroups of children, by
type of health insurance and so and so forth. So, I will leave you with that.

Let me go on to the measures, the three different measurement tools. So,
let’s just look at the AP definition. It has seven different definitional
components, which Dr. Tooker and Greg have talked about being accessible care,
family centered care, continuous, which is very difficult to measure and is not
represented in either –- we also reviewed MAPS by the way, which is going
to be dealt with tomorrow specifically. So, I’m not dealing with that –-
but continuous care is actually not represented, partly because of the way you
sample for patient input is they have to have already been enrolled for more
than a year usually in a health plan. Continuous care is a conundrum that I
think we still need to deal with. And I’ll mention that more later.
Comprehensive care, coordinated, which could mean many things, comprehensive
and culturally effective.

So, all together, there are 37 specific concepts, and to operationlalize all
of those 37 would take multiple items through each one. So, obviously that’s
not feasible. We took all 37 and said, well, which ones relate to all children,
which ones relate just to children with special healthcare needs or both. And
this is kind of how it fell out.

Twenty-four of the 37 concepts really were relevant for all children, and
the remaining having more relevance for children with special healthcare needs.
That was important for the CAHPS tool because it allows children to be
certified by whether or not. And to compare those two groups is actually a very
useful and important thing to do.

So, then looking at those 30 of the 37 were amenable to self-report in terms
of being able to imagine that you could collect this information in a
meaningful and valid way hopefully from people themselves. So, there are a
number of things like registries, which it sounds like providers aren’t’ even
sure that they can report on. But, it is difficult. Obviously, you aren’t going
to ask patients whether or not they are in a practice that has a registry. So,
we don’t look at those things in this. And that’s where this is complementary
to those other systems.

So, you have the structural aspects, which really have to be measured
differently to some extent. Not always. So, let’s look at the CAHP survey. The
first is what are the floor criteria? What’s the baseline you have to meet in
order to consider to have a medical home? And the unique thing about the CAHPS
instrument compared to the other two national surveys is that there isn’t a
floor criteria. You can actually meet the criteria in a number of different
ways. And that distinguishes it from the other two. So, I’ll tell you that and
say more later.

So, the child has at least one healthcare provider is the first criteria.
And again, it’s not a floor criteria. You can still meet the medical home model
if you didn’t. Accessible care and I’m curious about how many people are
wondering why that is. There are a number of people who have a usual source,
but don’t have a person that they think of as their personal doctor or nurse.
And there are a number of lower income families that get care in federally
qualified health centers and see a different provider, but they still meet a
lot of criteria for having a medical home. So, I think this is a key issue of
is it a person or is it a place. And if it’s a person or a place, that’s a
different way to measure it.

And there are some indications that having a different person each time
actually can raise the information level because they ask similar questions.
They don’t assume so much. And in other cases, you really need those personal
relationships to be consistent. The jury is still out on whether or not you
will always want it to be a person versus a place. Accessible care. In the
CAHPS survey, there are four times around getting care quickly. Many of you
know about these. Family centered and compassionate care is a composite made up
of four concepts. The personal doctor or nurse knows the child’s health and
health history. The doctor communicates well, which is defined by five items.
Information that is needed is received. Questions are answered, and shared
decision making, which is four, questions the classic that Sherry Kaplan and
Shelly Greenfield and others have developed numerous years ago around diabetes.

And then comprehensive care is also made up of a number of components and
then finally, coordinated care. And in this case, it’s very low bar. If you
have more than two providers, does anybody help you coordinate that care? And
it’s asked in a way with a preamble to hopefully help people understand what
that means. Very low bar around care coordination in general in all of these
tools. And then finally, culturally sensitive, which is really targeted for
those who do have language issues and whether or not they have interpreter
access and language barriers.

We have three different scoring approaches. I think you always have to have
a flexible scoring approach because zero to 100 continuous can be very
important for understanding variation and using it in studies and in regression
approaches. Then you also need for communication some kind of yes/no. Do they
meet the bar? And for that, there’s two main ways, the all or nothing. They
meet a minimum threshold on everything that I just outlined or average. On
average across all of them, did they get it? Which means they could have gotten
zero in one place and 100 somewhere else and maybe work it out still to have a
medical home

And the paper that I mentioned earlier has reviewed these approaches as well
in showing the different stories that get told. Having different scoring
options make sense when you’re dealing with something that has a lot of
complexity to it and you want to be able to communicate about it in a complex
way.

So, what do we know from the original testing that was done across 14 health
plans, the threshold on average across all subcomponent with 64.1 percent and
for the on every about 44 percent. So, obviously, if you have to meet all the
criteria, it’s harder to be counted. And then the issue of having a personal
doctor or nurse. If you have to have a personal doctor or nurse to meet the
criteria, fewer people meet it. So, if you don’t need to have a personal doctor
or nurse, more people meet it.

In terms of variation, we see about a 25 point variation across the health
plans. Twenty-five to 30 point variation across the health plans. And this was
actually in Washington State, where they do have a medical home requirement in
Medicaid and these were on the plans in Medicaid in Washington S tate as
represented here.

So, let me go on to the National Survey of Children with Special Healthcare
Needs, which Dr. Blumberg is going to give you a more detailed account of
tomorrow. I have the difficult job of reviewing a lot in a little time, but
there are many resources to get more detail.

In the case of the National Survey of Children with Special Healthcare
Needs, there is a floor criteria. You have to have at least one healthcare
provider. And there could be more than one because in the case of children with
chronic conditions, they often think of their specialist as the person that
they really look to. And so, we learn the hard way that we have to stay at
least one and not just one because if we say just one, about 15 percent of
people say no because they actually have two. So, we can’t leave them out. So,
we learn the hard way.

So, at least one person that you consider to be your child’s personal doctor
or nurse who knows their health and health history. And a usual source for both
sick and well care. And this really comes from the Maternal and Child Health
Bureau’s commitment to have both sick and well care in the same place.

Receives family-centered care. And the way that the scoring goes here as
everyone’s assumed to have a medical home and then they get knocked off if they
don’t meet the criteria. So, if you don’t have a personal doctor or nurse and
so on, then you don’t have a medical home.

Receiving family-centered care, which is defined in a certain way. No
problems getting referrals and this was a switch from before, which was no
problems getting specialist care. It switched to no problems getting referrals
because that was considered to be something that a personal doctor or nurse
could actually control more, and not whether you actually receive the care. And
this is where the systems versus personal doctor or nurse model comes into play
the most is around the issue of comprehensiveness and access to specialized
services.

And effective care coordination, which was a very very low bar in this case
and really targeted to people who needed professional care coordination and not
your average person with five different doctors who might need some help.

And then in terms of what we know. There’s about 47.1 percent of children
with special healthcare needs, which was the focus of this survey, have a
medical home and the state range again around 20 points. The variation within
states is even larger across different types of children according income,
according to type of health insurance, according to their race, and that’s
where that bookmark I gave you can help you find out more about that if you
like.

For the national survey of children’s health, there are floor criteria
having at least one healthcare provider considered to be a personal doctor or
nurse. Having had one ore more preventative visits during the last 12 months,
which is key for children because well childcare makes up a core of pediatric
care. And if you don’t have a visit for well child care, that’s considered to
really de facto mean that you really don’t have a very good medical home that’s
getting you in for that recommended care.

Receives family-centered care. Again, measured in a similar way to the CAHPS
survey. Consistent access to urgent and/or phone advice from the child’s
personal doctor or nurse, which is very critical for children who have
approximately 1.8 acute illnesses per year per child.

So, there’s a lot of acute care needs here. And no problem getting
specialist care, or if you did, you got help. So, it’s a slightly higher bar
than before. And then effective care coordination again measured more in terms
of if you have numerous providers, does anyone help you. Also, did anyone
follow up with you after you sought care outside of a personal doctor or nurse?
And that’s actually a very interesting measure. Did your personal doctor or
nurse follow up with you afterwards was the way that that was operationalized
as well.

So, what do we know there? I’m separating here by all children and children
who meet criteria for having a special need around 44, 45 percent meeting
criteria. The range across the states again, in the 20 to 30 range. A little
bit larger of a range for children without special healthcare needs.

So, key issues that were considered for operationalizing. These working
definitions are still the issues that we need to continue to consider. First of
all, what’s the content? What’s to include for everyone versus the people who
have chronic conditions and what we know is that no person is just a person
with one chronic condition. If you’ve got one, you’ve got multiple. So, what
does it really mean to be condition specific here versus looking at what type
of special needs people actually have? What are the service needs that people
have? We’ve done some work with CMS and others on think about that for adults
and children.

Also, what are the differences by age groups, especially for children who
are developing? There are different needs and so on. Assigning values to
responses and weights to components. Is everything created equal? Are all
responses created equal? Does never mean the same as always. And equal or
unequal weighting. These are all the issues that were considered in the
development of these tools that I’m mentioning and continue to be relevant.
Setting scoring floor criteria. I mentioned that already. Whether you have to
have a place or a person. One person, could it be more than one person. If the
person is experiencing medical hominess is that enough or do they have to meet
criteria that we think is there.

And finally, maximizing the value of the data for reporting and improvement,
which is key to how it’s scored. Being able to make sure that there is a person
level measure that can be combined with other kinds of level measure that can
be combined with other kinds of information like their eligibility and their
utilization of care, because then we have a powerful dataset that allows us to
really understand what’s going on.

There’s a lot of scoring models that don’t do that. So, we have to make sure
that the sampling and everything is done in a way where we have person level
data that can then be scored at the aggregate as well as child level.

Other issues which will be in my slides are ongoing about validity,
anchoring, breadth versus depth, and so on. And there are opportunities for
linkage to administrative and other data is a key issue again because we want
to be able to learn from this.

And somebody mentioned, Dr. Green, the end of one I think is something to
consider. That there really is a need for multiple models of medical home. And
that’s not what this slide says, but I’m going to say this now. That if it’s
really about meeting the needs of people in terms of needs met criteria for
medical homes; we know that those needs differ. So, it is difficult to apply a
standard criteria. And there are ways to customize care and find out where
people are at, both in terms of their need and their preference, both of which
should be considered.

So, we know something about looking at patient activation and about where
people’s preferences are for shared decision making, which does actually impact
outcome and costs when that’s done. There’s a lot of literature on that. But,
we really, I think, need to be thinking about a needs met model and different
ways of characterizing after we figure out what those floor criteria are, which
I think we can.

And the parent report or the patient report was used in these cases. It’s
most amenable to uniform data collection, which is still not true yet of
administrative or medical record data. So, that’s one reason to use it. The
other is that leverages are already in place.

Data collection tools as Greg mentioned, there’s the clinical groups CAHPS,
which is in place. So editing it and refining it. The mechanism is already in
place to use it. So, that’s a really good advantage. And the other is again,
the medical home is largely defined in terms of meeting the needs of individual
patients. And that’s always going to be different. And so we need to think
about customizing.

Our next step goals are looking at provider level assessment, which we’re
kind of doing, but not in a formal research context. We don’t have a formal
project right now. In continuing to integrate methods, we have a call –- I
told Don I could only spend a couple of minutes talking to him after the
meeting because I’m doing a memo for a call on Thursday to refine the way we
measured medical home in the next version of the National Survey of Children
With Special Healthcare Needs. So, we continue to look at opportunities to
improve and integrate.

Building off current efforts to understand outcome and costs, and I believe
getting information to people about cost could be a really important thing if
you want them to be meaningfully involved in their care.

And then further specifying measurement options that are low hanging fruit
for already endorsed measures. And I’ll just use two for children, such as the
promoting healthy development survey and the young adult health care survey,
which an adolescent self report. Transition into adulthood is a very important
issue. And how do we operationalize medical home for youth. We’re close. We
could get there quickly and I think we should look at the tools that are
already out there and endorsed and have many of the components in them just
along the lines of what I’ve been talking about.

And I do want to acknowledge a number of research partners and advisors,
especially Barbara Starfield who will be here tomorrow. And I think she would
support registries. She just wouldn’t as being the only way to measure it, I
would think.

Bonnie Strickland, who is actually up in Boston where I was going to be
today, at an evidence-based review meeting looking at the evidence for medical
homes. We have a long way to go. I hope we can figure out a way to learn
outside of randomized control trials as we practice care, and if we don’t
– we really will. I’ll be gone before we figure out if it makes a
difference. At least I think I probably will be and a number of other people.
So, thank you for your attention and time and I hope this was useful to you.

DR. STEINWACHS: Thank you very much. Let’s open it up for questions,
comments. I think you’ve razzle dazzled the committee, the two of you here.
Okay. Larry.

DR. GREEN: I’d like to ask you to say more about two things. You very
quickly went by close to the front of your presentation, if I heard you right;
you said there was a conundrum of continuous care. Could you just explain what
you were thinking about there and what that means? And then, it seems to me
that you raised a bunch of important issues, but one of them is, if I follow
this correctly, you are usually using a surrogate reporter in behalf of the
individual that’s getting care in the medical home. And much of your datasets
are presumably it’s a child of some sort whose parents are designated hitters
completing the information on behalf of them, right? Do I have that right?

DR. BETHELL: Yes.

DR. GREEN: Could you just talk about the methods of how you get that done
and how you do the translation and how you assign that with an eye toward what
it would be like to apply that to Medicare beneficiaries?

DR. BETHELL: Absolutely. And there has been some work on proxy measurement
in Medicare as well. So, I think we have a lot to build on. And for children,
it’s more obvious that it’s a family affair getting healthcare, and that the
parent’s experience of access on behalf of their children.

The provider is meant to involve the child, and there are some questions in
the CAP survey that asks about that, whether the provider actually talks to the
child and not just the parent. But, the proxy measurement, I think really says
–- one of the things that I wanted to actually say is there’s a concept in
child development called a good enough mother. And I think that there’s a
concept called the good enough medical home that we may not need to think
about. Because when you have proxy measurement, you’re always going to have
people who are more motivated responding and who are able to respond.

So all the patient reported data or parent reported data is an optimistic
view of what’s happening out there. Both because of how you sample – and
this will get to the continuous care issue that usually sampling is done for
people who meet certain baseline criteria of having a relationship already with
the system, and so they don’t even get into the sample until they’ve been
enrolled for a certain period of time. At least six to 12 months. So, that’s
already getting you higher up the scale. There are language limitations, and
usually, how these surveys are done, English and Spanish, and in Washington
state some other languages.

So, in terms of proxy, it is the standard for getting care for children
about healthcare quality for children up to about age 11 or 12. And then the
young adult healthcare survey, which I mentioned at the end, does start to pick
up at that age for children who are entering adolescents.

Where it is important to get care information from them directly about both
their health and their healthcare experiences and to begin to establish that
private and confidential and personal relationship with the doctor.

So, I don’t know if I answered your question about the surrogate piece, but
I know Ann Riley from Johns Hopkins does have some ways of getting data
directly from children and youth. And if a mechanism were put in place to do
that, I’d highly recommend it as a supplement and an important piece.

In terms of the continuous care conundrum, it’s just really difficult to
figure out what we mean by it. What is continuous care and for different
people, does it matter? Or, is it having a normal place where they have your
health history? And again, this issue of sampling really puts a wrench in the
wheel because you’re already starting at a higher level.

DR. STEINWACHS: Greg?

DR. PAWLSON: One of the things that is really critical for this committee to
sort of think about is first, as Christina pointed out, I think that the two
different methods or approaches are very complementary. I think we also have to
consider the clinical measures and the resources use measures if we’re really
going to look at the impact.

And I think that we’ve been struggling along since –- we are also
funded by Commonwealth, or have been at different times -– the conundrum
of what you can measure at what level, because we’ve had a terrible time as
Christina knows, having worked with us, even getting health plans to the
chronic care child. I think it’s the lowest care of any of our CAHPS measured.
Virtually everyone does the adult CAHPS. Many plans do the children’s CAHPS.
And many, many fewer, a handful, do the chronic care. And it’s really a
pressure of who makes them do it. If Medicare or whatever requires it, then
they do it. If they don’t, then they often don’t.

Measuring patient experience of care at the individual site or practice
level is a real challenge. I think it can be overcome, but it’s right now
potentially expensive. You can’t just hand out the questionnaires at the
practice and say fill it out and send it back.

There has to be some sort of permissible sampling. And we’ve been working a
lot with Dana Safran who was at Tufts and is actually now at Blue Cross/Blue
Shield of Massachusetts and has done a lot of work on the adult CAHPS. The
predecessor of the clinician group CAHPS called the ACES Survey, to look at
things like how big a sample you have to have. I don’t know if you are aware of
his work?

DR. BETHELL: We worked with NQF on CAHPS.

DR. PAWLSON: How many you have to sample, which questions have the most
practice variation at the practice level, not the health plan level and then
how does the practice – if this is a quality improvement model, how does that
information get fed back to the practice and how does the practice use or not
use it in improving their care? There’s actually a nice connection in that
there’s about six or eight points on the physician practice connection practice
evaluation tool that relates to whether or not the practice does some kind
– and it really allows them to do just about anything right now –
some kind of patient experience of evaluation and then whether they actually
use that in improving their practice. So, there’s a potential loop here, but
there’s a lot of really major measurement issues that still have to be kind of
worked out before we know, I think, how this is going to work on either a
regional level, a national level, a site level, or an individual practitioner
level.

Since a lot of the thumbprint on some of these questions on the patient
experience survey is not site level, they are actually individual clinician
level. Does you doctor listen, for example.

DR. STEINWACHS: Matt, I’ll let you have the last question here before we go
to the next.

DR. QUINN: One of the really fundamental aspects of what I think of as a
patient-centered medical home has to deal with care across setting and across
care providers, and that unfortunately is also one of the least developed in
terms of communication infrastructure. Can you talk about the level to which
organizations in your assessment are able to do that and how you’re able to
measure that?

DR. BETHELL: I can tell you a little bit about the measurement. There are
some. NHQ has been working on getting service agreements between primary care
and specialty care, and of course, this is the issue around patient safety as
well, when we see problems in safety communication across providers is one of
the key issues. So, it’s very very critical.

In terms of how it’s measured in the tools that I mentioned to you, in the
two national surveys, which also provide state level data and some regional
level data, there are questions asking about whether or not the child’s doctor
communicates with the school, which is very key for kids. The school-based
piece is huge and also other providers and whether there is follow-up when they
do see another provider. Like, do they know what the results were or something
like that?

And that’s what actually drives the measure down. That is the component of
the medical home measure that drives the scores far down. I think 39 percent of
those really needed their doctors to communicate with the school and other
providers and said that that happened in a satisfying way. Most are saying it’s
either not happening or it’s not happening well. So, you’re right on the mark
about that.

DR. STEINWACHS: Christina, Greg, I want to thank both of you very much.
You’ve given us a lot to absorb. Christina told me that would be the challenge
here and Greg did too.

So, you’ll probably hear more from us in the future as we try and sort out
and understand. I thank you very much.

Agenda Item: PCMH In Practice

DR. STEINWACHS: We’re now turning to the next session on patient-centered
medical home in practice and drawing on the experience that’s available. We
have three presenters. The first, Terry McGeeney.

He’s a clinical assistant professor at the University of Kansas School of
Medicine and President and CEO of AAFP Transform Med, which I saw a beautiful
model of how all the pieces should come together. And I assume you are going to
share some of that with us now. Terry.

DR. McGEENEY: Thank you for the opportunity to be here. Transfer Med is a
subsidiary of the AAFP, and I think one of the things hopefully the next three
of us can do a little bit is connect some of the dots that have been laid out
so far this afternoon.

And what you’ll notice is an awful lot of synergy. None of us are operating
in a vacuum. We all hear each other’s presentations quite frequently and all
work together quite frequently, but that’s been a very powerful tool in moving
the agenda forward. To echo something personally that John Tooker said this
morning, I had the pleasure this weekend of a son and daughter-in-law who both
graduated this weekend from medical school at the University of Kansas, less
than 10 of the class of 176 went into primary care. Pretty scary. That’s
Kansas. It really is a crisis across this country. This is more than an
interesting academic exercise.

The opportunity today, I think, is to discuss kind of the ground level as it
were what the patient-centered medical home is with our perspective. The
American Academy of Family Physicians, as John mentioned this morning, did a
Future Family Medicine Report from 2002 to 2004. At the end of that, it said,
as John stated, that primary care was in trouble. It also defined a model of
care. Then it was called the new model of care. Now, we call it the
patient-centered medical home.

The AAFP decided that a proof of concept national demonstration project
needed to be done, which we called a learning lab in a sense, to really flush
out what works, what doesn’t work and how you implement this model of care. So,
the opportunity I have this afternoon is to talk about real world experience.
Not just theory.

It was also commented today that earlier this afternoon, the difference
between a medical home and a medical house. That kind of fits well with my
slide because when I teach physicians, we first talk about a medical house and
the building blocks of a house. You have to get it pretty concrete. The other
thing to point out is the model care that we are testing and learning how to
implement in our demonstration project, which we are just completing, we
decided in mid-2005. So, a lot of this was developed by the best thinking of
the time based on a lot of work from IHI, Future of Family Medicine Report and
others. So, it’s been around a while, and thankfully, it fits quite well. But,
it is a research project. It is a learning lab. And I don’t mean to sit here
and say that the model that we have tested is necessarily exactly the right
model. Just as Greg Pawlson said a few minutes ago, we still don’t have quite
figured out how to test the model because everything is in transition. But,
it’s being done in a very calculated way.

So, as we look at the medical house, there are certain things that are
important. Quality and safety, continuity of care services gets to be the
collaborative care. Continuity of care, all those things we talked about
earlier, point of care services, doing what the patient needs when they needed
it.

Information systems. We’ll be talking a lot about that tomorrow. We spent a
lot of time on that. As was commented earlier, one of the things that we’ve
learned over the last couple of years was how critically important population
based, technology based registries are in the chronic care model.

We really didn’t understand that fully a couple of years ago, access to
care, access to information. That was talked about today. That relates
specifically to the patient. Team based care; John talked about that this
morning. And keep in mind, we did this back in 2005, being critically
important. And another comment from something that was made just a few minutes
ago. We made a decision back in 2005 that for the patient-centered medical home
for our purposes is a practice.

Every patient in the practice should have a personal physician, but for
intents and purposes as we worked to implement the medical home, it was a
practice. We then added something a little bit outside of the medical home as a
solid foundation and practice management because we fully understood that if
you did all these cool things and the practice went broke, it really didn’t
matter too much.

So, we spent quite a bit of time with practices just working on business 101
as well. And all that is the overarching philosophy of patient-centered care,
which we start drifting away from the house and trying to get to the home. And
the definition. A continuous relationship with a personal physician caring for
the whole person.

As John said this morning, we don’t say family physician, we don’t say
primary care physician, we say they must have a personal physician, but that
personal physician must be willing to step up and provide all of the medical
home components within his practice environment.

So, wet take all of those things and that’s what we now call our Transfer
Med Medical Home for purposes of our project, which is the patient-centered
medical home. But, then we take that whole thing and then we flip it. And we do
that because now we put the patient in the center. It’s all the same tenets.

The talk goes on much longer, but each of these things has a lot of things
under it, but the point being it’s the patient that’s in the center with that
continuous relationship that cares for the whole person. And that’s when we
would try to start moving it from a house to a home. The things I want to talk
about again at the ground practice community level are today’s realities and
tomorrow’s opportunities.

Maximizing today’s realities. Practices have to become viable in today’s
environment. The project that we were tasked with was not doing a project
assuming there was new money, assuming that there was some boatload of funds
coming down to reward practices for doing this. It was enticing and working
with practices in today’s payer environment to become patient-centered medical
homes.

They also must provide what the patients demand. They also must provide what
the United States healthcare system requires, and there has to be a quality of
life focus for physicians, or the pipeline is going to continue to dry up. And
the timeline is short. The FM report in 2004 stated that primary care was not
tenable in a 10 to 20 year timeframe. And I think there are a lot of us in this
room that still believe that.

Tomorrow’s opportunities. There are a lot of pilots out there. There are a
lot of things going on with demonstration projects. But, practices have to be
positioned to be able to participate in them. They have to get a level one NCQA
recognition. They have to commit ultimately to being in a level three. And so,
it will be a travesty if CMS decides to do a pilot and there aren’t any
practices that can participate. And we do feel that practices need to be
complete medical homes.

Now, we are just winding up a national demonstration project. It was an $8
million project, funded entirely from AAFP reserves. There was no payer money,
no pharma money, it was all Academy money. The only disclaimer to that is like
everybody else at this table, the Commonwealth Fund did approach our research
team and want to expand their work around patient centeredness. Specifically,
how does a patient perceive all these changes relative to medical home.

We chose 36 practices from around the country. We had a 17 page application
process. Five hundred and fifty practices applied and there was no new money to
these practices to do this. The caveat was that the practices had to commit to
implement as much of this new model, not parts of it, all of it, as feasible
within their environment in a 24 month time period. A Herculean task by any
standard.

We then broke the group up into two subgroups. Eighteen, we aggressively
facilitated. Those are advanced degree, PhD, MBA types with at least 15 years
of management experience working aggressively with these practices. Site
visits, conference calls, webinars, collaborative meetings, and then we had
another 18 practices that had to try and do the same stuff on their own, with
no outside support. The goal was to figure out how much support is really
needed to help practices transform into patient-centered medical homes, which
is important for a lot of reasons. Not the least of which, I think all of our
professional associations need to know going forward how we support our
membership.

All practices were studied equally and independently. We had a research team
that involved six academic institutions from around the country. It involved
PhD statisticians. It involved registered nurses visiting the practices doing
chart audits. And that was completely independent from the facilitation
component. The facilitation component ends May of this year. We are going to
continue to study the practices for another six months with more visits from
the research team to see if the trends continue, to see if there is fall back
and hopefully get further learning.

This is where the practices were located. They were large. They were small.
They were urban. They were rural. We also thought that was important to know
what would work in a large practice wouldn’t work in a small and vice versa,
urban versus rural.

As John pointed out this morning, many primary care physicians are in groups
of six or less in this country. And many many of them are away from the
population centers. So, it was important to us to study all of those different
demographics.

Another thing to just make mention of because it came up this morning as
well, we have another demonstration project going on. It’s called P4, which is
preparing the personal physician – again, we’re not saying primary care
physician. We’re not saying family physician – for practice. It’s a
residency demonstration project, where we are actually trying to learn new ways
to train family medicine residents in how to be able to practice in medical
homes when they leave their residency environment. Much of what, I think it was
John, mentioned this morning.

To that, we’ve had two collaborative meetings to date and with a hotbed of
research, the University of Oregon is the independent research component of
this project. So, we are studying different ways to train residents. That’s
different than making the family medicine outpatient centers medical homes.

And it’s clear to us that family medical residents must also learn and
practice in medical homes. So, back to the NDP. But, I think it’s important to
learn that we’re trying to deal with that whole continuum. We do end it May
31st of this year. As a disclaimer, the Academy gave us $8 million.
We only spent about seven of it. That made them very happy.

And we have actually – this slide is a couple of weeks old – we
actually have several practices now that have implemented all of the components
of the new model within a 24 month period of time. It is possible. And we have
had the collaborative meeting that brought all of the facilitated and
self-directed practices together for the first time. And that was a fascinating
experience.

Some of the things that we’ve learned that I think our relative going
forward is we learned how to support primary care in becoming medical homes.
Primary care practices are not prepared to change. Most primary care practices
are not motivated to change. That goes back to what Greg was saying earlier.
It’s tough without dollars involved. There are certainly some in our
demonstration project that were highly motivated and were willing to do it
without any extra money, but when you get out to the rank and file, it could be
an issue.

Primary care practices are woefully uninformed. We recently did a survey
that only 52 percent of family medicine practices have ever heard of the
chronic care model. We have an awful lot of work to do in this arena. And
that’s something that I think is critically important to understand.

Leadership at the practice level is lacking, particularly around
transformation. Communication is a major limiting factor within a practice.
Electronic visits were discussed this morning. They are not well accepted by
patients. A lot of patients would much rather take off work for a whole day and
get paid for it than have to stay at work and do an e-visit. So, the incentives
again are very misaligned and we’re finding that the practices have embraced
them. We put in the technology, but patients aren’t wild about them because
it’s a lot more fun to take off work, unfortunately, and get paid for it.

Access and cost of care are primary importance to patients. They assume
quality. EMR and efficiency are backhaul issues. In a lot of my talks, when we
talked about electronic health records, I used the analogy when you go to your
ATM and stick in your card, you want money back. You don’t care if it’s the
best IBM technology or three short people giving money out of a cash drawer.
That’s really where patients are with electronic health records and quality.
They just assume the practices are going to do it. And we’ve learned that in
spades, we’ve sent out over 17,000 patient satisfaction surveys. And a lot of
the stuff that we’re learning is that kind of stuff.

I mentioned earlier that registries are critically important for chronic
care, but practices are unwilling or unable to do manual entry of data.
Registries must be self populating. They must be associated with the ability to
store and transmit data, and we’ll talk about that more tomorrow. But, if we
are ever going to be successful around chronic disease, we have to be able to
get registries to self populate and we have to be able to use that data and
move it around between various entities.

And we have actually successfully done that in eight practices with
different EMRs in our national demonstration project. So, this is not pie in
the sky technology. This is technology where I can sit in Kansas City and look
at a practice in Iowa and see how many diabetics they have. Which diabetics are
with which doctor? What is the average A1C of a diabetic in the practice?
What’s the average A1C by doctor, by patient? Which patients haven’t had their
colonoscopy this year, and on and on and on and on. It’s not pie in the sky
technology. It’s real world stuff that we need to figure out how to move it
forward.

The biggest concern about technology implementation is operational, not
cost. Loss in productivity, losing data, and all of those kinds of things. Most
practices think they are providing quality, but most are not. We all know that
to be the case. Safety at the practice level is woefully inadequate. A lot of
the work is done at the hospital level. Not a lot of work is done at the
practice level about sample safety, immunization, drug errors, patient
education around pharmaceuticals, all of those things that are truly practice
responsibility.

As mentioned earlier, understanding and expertise of business issues and
practices is solely lacking. Practice ownerships, particularly by hospitals,
limit medical home implementation. As John mentioned earlier, the hospital
world is finally starting to talk about medical home a little bit, but it’s
been very very slow to come. And in many cases, 54 percent of family physicians
in this country are employed by hospitals. And it’s important that we bring
that whole arena along.

Many providers have lost their skills. Refer too easily and lack confidence
in procedures. Much left over from the old HMO days. Advanced access scheduling
is poorly understood and therefore, poorly implemented.

Team care is a difficult concept for family physicians to grasp. We were
taught captain of the ship. We were taught we know it all. We were taught
everything is our responsibility. And that has been a terribly difficult thing
to teach. But, it is critically important in the patient-centered medical home
concept. The larger the practice, the harder it is to transform.

You hear a lot of conversation around the country that small practices don’t
have a chance. In reality, what we find out is the smaller the practice, the
easier it is as long as you give them the support. The positive. Population
based registries do work and are a critical success factor.

Quality outcomes. Metrics do modify behavior. Team concepts really do work.
They lead to higher quality, greater productivity and improved job satisfaction
by providers and staff. Practices can do well in today’s payer environment when
operated as a business.

Practice websites are popular with practices and patients. E-visits work,
but patients seem to be better motivated and the incentives need to change.
Patients and providers both like group visits. Advance access scheduling really
works. Eight percent of our practices have increased their capacity without
increasing their workday. The entire model of care can be implemented. Point of
care. Evidence-based reminders improve quality and provider satisfaction.

Technology will allow that when a patient comes in for a sore throat,
technology can remind them that the patient is due for a tetanus shot or
colonoscopy or mammogram, whatever. When the provider has to wade back through
the record to do that, it often doesn’t occur.

The critical success factors for EMR implementation are change management
and planning. It does not have to be traumatic. About half of our practices had
EMRs at the start of the national demonstration project. Now, all but one does.
So, in light of everything else, we did full EMR(?) implementation in most of
these practices.

Another thing that is important to keep in mind is that the components of
this new model are interdependent. You really can’t do successful chronic
disease management unless you deal with your access issues. Unless you deal
with your patient education issues. Unless you deal with the ability of the
patient to access their information. They are very independent. Another thing,
and Greg alluded to this a little bit, doing things does not create a
patient-centered environment.

One of the things we’re all struggling with is that you can check a whole
lot of boxes, but you still don’t have a patient-centered medical home. So,
then it gets to be a real challenge on how you measure that. There’s some sole
of the practice that is very hard to quantitative. And then interesting enough
and it’s kind of antidotal, but an inverse relationship between the time the
provider spends with a patient and patient satisfaction. They are very
concerned about how much time they spend in the practice and who’s doing what
and the right things are done by the right people at the right time. It doesn’t
matter that the doctor spends an hour with a patient and asks about Aunt
Nilly’s rheumatoid arthritis for the fourth time in a row. So, it’s really a
challenge to us to get into that team concept, right care at the right time,
right sizing.

Some bottom line things in practices that are kind of important to just
briefly touch on because primary care practices, the reason they are failing
and residents aren’t choosing them is because the economics aren’t there. They
can’t even service their medical school debt.

But thinking inside the box, but typical business principles are lacking in
practices. Primary care practices today, AAFP data, MGMA data, and our own data
suggests they only see between two and four patients and hour, but they are
very very busy doing all the junk, filling out all the forms. The nursing home
calls, the drug company prior authorizations, on and on and on. They’re doing
all this stuff, including a lot of the CMS stuff and they can’t see patients.
They need to see at least 3.3 patients an hour to be economically viable in
today’s environment.

Operational inefficiencies are an issue. Another thing that is important is
that practicing good evidence-based medicine can generate more revenue for a
practice. What’s that mean? It’s a cost to the payer. So, one of the challenges
that we have going forward is that every patient gets ever test they are
supposed to get, costs could go up, which is a challenge that we are facing
going forward when we talked about all this budget neutral things.

We’ve got to be sure to look at everything across as continuum, and it may
be that as Chris talked earlier, spending money now on the diabetics may
prevent them from being in diabetic ketoasidosis, getting their leg chopped off
and going blind 10 years from now. But, the costs today may actually go up,
which is something that we’re really, really going to have to struggle with and
spend some time thinking about as we move forward.

Group visits are not a cash cow, but they do pay for themselves. And almost
across the board, we find that in primary care practices, mid-level providers
are poorly utilized again, because of the team concept. So, hopefully, I’ve
been able to share a little bit is real world experience, we have done this in
36 practices across the country for the past two years. Medical home can be
implemented. It does work, but there’s yet an awful lot of work to be done, and
thank you.

DR. STEINWACHS: Terry, thank you very much. That’s really exciting. Let’s
move on and then we’ll have questions at the end. The next presenter is Dr.
Alan Dobson. Allen is vice-president of Carolina’s Health Care System and
formerly Assistant Secretary and Medicaid Director. So, I guess you’ve gotten
to see the system from different vantage points. Allen reminded me that some
people share the same name. So, I expected someone with a different face.

DR. DOBSON: Thank you. It’s a pleasure to be here. I’d like to just kind of
walk you through North Carolina’s experience with the Medicaid program. And as
a disclaimer, I want you to understand that we started this project in 1999,
and really implemented it in 2001 with the budget crisis. So, we kind of
predated down this road before we started talking about medical home. So, as
you see what we’ve developed in North Carolina Medicaid program, I think you’ll
judge for yourself where we are. In fact, I was talking to Greg about the
interest in going back and looking at all our primary care physician offices
and actually seeing how many of them really certifies twos and threes after
about eight years. It would be very interesting. I know a lot of them have
already.

I’m going to run through this pretty quickly, but again, our goal back in
1998-1999 was on the tail end of the gatekeeper model, which had produced
access, but not any quality or cost savings, and there are many reasons for
that. And we started off with what was a fairly well controlled experiment in
1998-1999, until 2001 hit and we suddenly were faced with budgetary disaster at
the state level, at which time the governor said, if this is your model, expand
it right now, otherwise we’re going to have to slash and burn the Medicaid
budget.

So, we went to work and crisis sometimes the best mother of invention. And
we rolled out what turned into be our community care network. So, we’re now
going back and studying what we did. Again, we realized that all of a sudden
the money – when you go out and rob banks that is where the money is.
Well, if you want to manage the Medicaid program, you go to where the chronic
illness is and the people who are sickest in the Medicaid program.

When we went and started looking at our old PCCM model and looking at what
we had in North Carolina after HMOs and the managed care exited Medicaid, and
we went to the source and we went to communities and talked to the primary care
docs and said, what’s the problem? And this is what they told us.

They said, we have not care coordination here. We don’t feel like we can,
with our increasing demands, we are not able really to manage the needy
patients in our practice. We really need some help from the state. And what’s
more, our communities were operating a system where public health, mental
health, home and community-based services were not coordinating at all with the
medical system. It was very fragmented. And what was worse was that the state
made it worse and functioned mainly as a regulator.

And we really wanted to look at kind of s more chronic illness model. And
these are things that are happening now that fit us, but our approach was
basically North Carolina is a rural state and wasn’t rally well conducive to
the typical managed cared approaches. We, at that time, had a lot of small
practices, loosely organized medical systems, and small two and three doctor
practices in rural areas. And our counties remained strong, but not well
organized.

So, we really wanted to look at our Medicaid population. Can we control cost
and improve quality? And again, our first pilots were around quality efforts,
not cost containment. And we wanted to develop some systems that would help us
manage our most difficult patients and really develop what was at that time a
personal physician, primary care home, but not a medical home.

Our key visions for the state were that if we were going to have to do this,
we needed more than a regulator; we really needed to be a proactive healthcare
manager. And that’s a real difference for a state Medicaid agency to go out and
partner with communities and providers in that sense.

And so, in its essence, community care is really a clinical program. It’s
not a government or a financing program. So, we created public private
partnerships between the state and providers and the medical home, a place
where usual care for our Medicaid recipients was key.

And we also wanted it to be physician led and community based. We wanted it
to be quality and system oriented, and we wanted to economize by raising the
quality and improving the care, rather than going in and typically lowering
fees.

So, basically our operating principles are we had to engage the physicians
in the community to make this work. But, beyond that, had to engage the
hospitals and health departments because it really is about the hand off. It’s
really about coordinating patient’s move through the system. And the ownership
of the process needed to be vested in those who really did the work, which is
at the community level.

So, we had to get people working together and focus on quality and we need
to provide the information because information is key to changing behavior. So,
community care is basically making sure people have a medical home, and we
create community networks that connect those medical homes to the rest of the
local communities.

So, if you’ve seen one of our networks, you’ve seen one our networks because
every community’s resource are really the same. This is really a function-based
system we have created in North Carolina between hospitals, health departments,
social services and a lot of other stakeholders now locally, including schools,
and mental health agencies and other social supports in the communities.

So, this was in 1998. When we envisioned some pilots, this is what it looked
like. And they were just a collection, whether it was out of a community health
center or health department or a collection of pediatric practices or health
departments, we were testing multiple models. But, now in 2008 we have 14
networks, 3,500 primary care physicians operating 1200 medical homes. We manage
actually 800,000 now Medicaid enrollees. And because of the success in the
budget, this legislature has asked us to manage the ACE fund and S-chip as
well. This is what the map looks like.

Again, networks of medical homes and community providers all across North
Carolina and they self select themselves. If you’ve been in government, you
don’t draw maps if you want to keep your job. So, very political.

So, what are our networks? Well, they are not for profit. They are all
inclusive of all providers, including the safety net. We asked them to have a
medical management committee, something that we can start doing practice
change. And we invest in those local networks by providing a PMPM payment for
the Medicaid patients. But, we also pay the practices to participate. It’s the
spin-off of our old PCCM access fee, but now it’s to participate in quality and
what we’re doing.

And because we’re rural, when we wanted case managers, rather than fund the
practices directly, we send the money through these networks and then some
practices get reimbursed for their staff if they are big enough to have it.
Otherwise, it becomes a virtual network for resources that are shared among
multiple practices. Another thing that makes this work is we pay fairly well as
a Medicaid program.

So, as we add more functions, we’re gradually increasing our PMPM payment to
the communities, including the aged, blind, disabled, that number has gone up
to about $6 or $7 PMPM because of the additional services we’re providing. Each
network has a medical director, care coordinator, and we hired case managers,
care coordinators. It’s a basket of functions they perform. And some small
practices share them, large practices have their own.

We now actually put clinical pharmacists in the networks and we have a pilot
going where some of the practice actually has a practicing pharmacist in their
practice. And I’ll tell you why in a minute. Well, I’ll go ahead and tell you.

When we looked at the reasons for admissions for congestive heart failure
and we were looking at telemedicine and things, the real reality is only a
third of the patients with congestive heart failure actually took their
medicines. So, it’s a real adherence problem in actually knowing what the
patients are on as they pass between the hospital and the practices and
specialists. So, clinical pharmacists, we felt could work within the team that
would help that. So, there’s more to come on that.

Key attributes of our medical home is just the entry level medical home –
access, arranging for hospital, coordinating care. But I think our key
innovation is the organization of our rudimentary medical home within a
community and creating some physician leadership around that because that’s
really what makes it work. How do you get practices to change? It’s really not
a new program that we pay for in Raleigh. It’s really about someone going and
sitting down in the practices. It’s less about the physicians then it is the
physician’s office staff. And another thing that we are getting ready to do
that I’ll mention is related to that – providing that practice health.

Another thing is including the safety net providers particularly for
publicly funded patients. Having the safety net providers at that table is
extremely important as well. So, we’re really about building local systems of
care. The most exiting thing is what really happens in our local communities.
We have practices who get together and then locally, their local management
committee gets together and we can drive change in Raleigh by saying we need
you to work on this. And then the local practices and the local community care
networks will pilot things of their own invention. And the best practices will
become state initiatives. These are some of the things we have done statewide.

Again, congestive heart failure, interestingly, when we did the pilots, we
discovered the biggest problem was really on medication adherence and case
management. We’ve done interesting things like dental screening by
pediatricians and family physicians because we don’t have dental access.

But, each network also does their own quality improvement. We also are
moving into new things; depression screening, e-prescribing, total location of
mental health providers. Again, trying to create some sort of system of care.
And what we’ve found is that by participating in some of these layering —
Robert Wood Johnson funded improving performance and practice — we applied
that to some of our networks and what we found was that practices needed help.
So, we’ve decided that we will fund our AHIC system to actually provide the
practice improvement specialist in all the communities.

It’s in the governor’s budge this year, as well as also the community care
networks will be funding those practice improvement specialists to go into the
practices to hopefully improve their performance.

Also, we have a new governor’s quality initiative, which is a multi-payer
initiative around improving practices performance. Particularly in our
ambulatory primary are practices.

So, our basic results, we monitor quality. We do claims and chart
extractions, but it is pretty low tech. We go in and measure our networks and
practices. That’s as close as we can get. But, we are moving Medicaid quality
to a fairly respectable range compared to commercial payers.

Now, it’s not respectable for best practice, I don’t think. But, we’re
actually moving the bar. In our early work, when we really did have some
randomized control trials, we did lower hospitalization ED rates and it
improved our performance, and then we started moving it out. So, we are kind of
the researcher’s nightmare. But, the big question is does it save money. And
the answer, at least in the Medicaid program is yes. According to Mercer, for
that investment in the PMPM, we’ve saved money from the Medicaid budget every
year compared to ourselves last year.

What these numbers mean is that on the left, this is the same counties that
were participating reduction in what we anticipated they would spend by new
initiatives for the following year. So, what we are doing is flattening the
rate of growth. So, it’s not cutting budget. It’s lowering the rate of growth.

So, in our women and children, we dropped our inflationary increases in the
Medicaid budget to four and a half percent per year, which is very respectable.
Over on the aged, blind, disabled, it was going double digits, which is why the
state mandated us to actually start managing them as well.

The right column is compared if we had done nothing. So, it’s fairly sizable
savings. And I can tell you, for the first year, our legislature has actually
booked savings on their budget in anticipation of changes. That’s how much
confidence they have that this clinical model will work. And I used to be able
to throw a little change out and the legislators walked around at the end of
budget time, but they’ve actually budgeted this.

So, let’s look at aged, blind, disabled. This probably mimics the Medicare
population a little bit better than a typical Medicaid population. But, we did
a pilot of 10 networks, 30,000 patients and as you would expect a lot of
prescriptions. A lot of them have co-morbid conditions. A lot of chronic
disease. Surprisingly, or maybe not surprisingly, almost 8,000 of the 30,000
had a co-existing mental health condition, which I don’t think we’ve even
really started to look at. And then again, we’ve got suggestive heart failure,
which we’ve found was mainly a medication adherence problem. We’ll find out
when we fix it if we fix it if we actually were to reduce hospitalizations.
But, one year of savings for that 30,000 patients was $53 million. So, you
extrapolate that to the rest of our aged, blind and disabled population in
North Carolina, that’s $250 million of potential savings by improved care.

So, can you save money and reinvest? The answer is yes. You just have to
marry the savings, the quality and reinvest in resource and not just let it
role back into the budget. That’s where the future funding will come.

Our next step is to strengthen the medical home. Again, going back and doing
the work. Since we were in such a hurry to roll this out statewide, it’s going
back and really investing and trying to raise the rest of the — get a little
bit better penetration locally and improve the functioning of all the medical
homes in each community.

Also to enhance the practices of the networks’ ability to support patient
self management. So, we’re doing group visits and some other things. Also,
integrate some of the specialists expertise. This was built on a primary care
system, and as we get into more complicated diseases, particularly in the
children with special needs population, you have pediatric neurologists, you
have a lot of hand-offs that are extremely important. So, we’ve invested in
care coordinators at some of the medical centers to enhance the handoffs back
to the local communities as far as communication.

Also information systems and a big one are Medicaid directors. How do you do
the duals because again, you’ve got two different programs and how do you
really manage them to benefit because when you do a good job with the duals,
most of the money accrues to the Medicare side out of part A. Or, if you do
some of the special needs plans, you end up spending more on home-based
services, which helps with hospitalization. So, we have really different kind
of initiatives. We’ve at least postulated and applied for a 646 demo, which
would let us manage it clinically in a third of the state and see what happens
on a total patient cost savings.

And our projections through Mercer were $1.4 billion over the five year
demonstration just on the Medicaid side of the house. So, it’s significant
savings by improving care. It’s just in different buckets. After eight or nine
years, I just want to talk about limitations and reflect on something Larry
said earlier is that if you’re trying to create a model and do it in the next
decade, I don’t think you can do double-blind studies. What we have found is
that the limitations of studying this are hard because of the multiple
initiatives operating concurrently in a community. Which one had the effect?

The other part is it was–I sometimes quip, our control group was last year.
That’s about all we can get to. It’s usually last year’s budget, not really
anything else because it’s really difficult to hold a control group if you’re
operating in a community. And really what was hard is physicians get excited
about really making a difference. And it’s hard to prevent sharing a beset
practice even though you might want to.

We’ve had a lot of trouble staring this so long ago having really solid
pre-intervention numbers from a population. And because of the pressure on
budgetary control, which we’re probably going to start feeling again with the
downturn of the economy, there’s a pressure on being a gunslinger and just
rolling out programs and not be as thoughtful. And each community really starts
from and practice starts from a different position. So there’s a lot of
variability and penetration of these efforts. I think we need small, but valid
sets of measures that we can carry over time to look at the entire population
because too many measures will actually make it more difficult for practices to
appear and to keep up with it.

I hear our docs hear I’ve got ADD because of so many things coming at me.
From a state perspective, we need evaluation help. States have limited
resources and it’s like a limited resources and quite frankly limited patients
for really doing good research and the resources for study are usually low
priority having walked through the legislature.

And the long-term success will require some on the ground system to reside.
I do not think that you can throw something out there and the system will
reform itself. I think there needs to be some more directed and more help,
which is I think what North Carolina was able to do through its Department of
Health and Human Services in creating this nice public-private partnership.

I guess my take home message would be there are key attributes of the
community care that I think are applicable to other states even though we are a
constellation of stars of what happened in North Carolina is not really
duplicatable, but there are some key messages that our journey through eight
years of developing community care, I think that the government should take a
more proactive role in defining what the system should look like, which is the
importance of this work around medical home and defining the outcome we don’t
see.

It’s not all about being a single payer. It’s all about being a single
system because as a family physician in a small town, we are the healthcare
system in my town of 1000, along with the local pharmacist. That is the
resources. And you’ll know that very clearly because we are an all payer
system. We don’t turn people away. I think there are some key principles as
we’ve talked about. IBM taking the lead. This is not about who pays.

I just think the government can take a more proactive role and understand
that this is a function based system. These are functions that need to be
provided for patients. I think they are best provided through a medical home
and a primary care physician, but it could be provided in a relevant sense as
we’ve done in many of our communities. Because our principles of community care
do allow for local variability. We have a website and we try to post all our
data. And I’ll say that the Commonwealth Fund and the Urban Institute, we’ve
got a lot of help right now in trying to go back and look at seeing what are
the core elements of success that we’ve had?

Again, ours is high level. It’s about managing the budget and getting better
care. And we know, at least on a global level, that we’ve done that, but we
don’t know all the moving parts and what are the most important steps to do
that.

DR. STEINWACHS: Allen, thank you very very much.

The third presentation is from Dr. Myles Maxfield, who is vice-president for
Health at Mathematica. Mathematica has the CMS contract for the evaluation of
the medical home demonstration. And just as you’ve heard previously from Jim,
it’s early in the process. So, Myles is going to try and share with us what he
could share with us about what the thinking is, I guess, and the directions
you’re pursuing.

DR. MAXFIELD: Thank you for letting us shares some thoughts about what some
of the implications of the medical home model are for data and data systems. As
Don said, my disclosure here is that we are teamed with NCQA to design for CMS
its medical home demonstration.

I want to be clear about the perspective of my remarks today. I’m going to
be talking from the perspective of an operating Medicare medical home program
within a fee for service Medicare environment. A couple of key points under the
implications of talking about an operating program. I’m gong to be focusing, as
I say, on data implications. I’m going to be — most of the databases and data
systems that I’ll talk about have to do with all of the participating
providers. They are not a sample of the providers. I’m not talking about a
research study here.

Another key point is that many of the needed data systems that I’ll be
talking about that seem to be either required for implementing a medical home
model or that would at least facilitate a medical home model, do not exist in
the typical practice and will have to be developed. They are going to be new.

Second, a broad point is that I am taking a broad view of data, which is to
say most of the databases and flows of data and data systems required to
implement a medical home are outside of any federal surveys program. And this
is one of the themes of my talk. Moreover, much of the data flowing among all
the parties to a practice and operating medical home, much of the data will
never flow to a federal agency. Obviously some of it will and we’ll talk about
which flows through the federal agency and which doesn’t, but I will be
focusing on even the systems and the databases that do not flow to a federal
agency and I’ll talk about why that is.

A third perspective is I will be using NCQA’s PPC tool as a template to
structure many of my remarks. So, many of the speakers today and tomorrow have
talked about what a medical home is and what it’s components are, why it is
important. I am not going to talk about that. I am also not going to talk about
the design of the CMS medical home demonstration. There are two reasons for
that. The first is that it changes everyday. The second is that CMS has not
made it public yet. And therefore, I am speaking on my own behalf. Not on CMS’s
behalf.

So, here’s my list of what a medical home is, and the reason I put it up
here is that these are the functions that will drive the need for data and data
systems. Maintaining long-term — care must be coordinated in two dimensions
months over time. Secondly, at a cross-sectional sense across all providers and
all care settings.

Care has to be delivered pertaining to all types of problems faced by the
patient acute care, chronic care and so on, including mental illness, substance
abuse and lifestyle issues. Obviously, there’s a focus on evidence-based care.
And lastly, we’ve heard from several speakers about access to care. I will be
drilling down and access to care and what the data implications of that are.

So, this is a useful triumvirate that helps me organize my thoughts about
data and data systems. What do we need data for? We need data to qualify
medical homes, which involves data flowing from the provider to — I’m now
talking about operating a CMS program, so flowing to CMS, CMS is likely to
develop a feedback report, which flows back to the provider.

The second big function is operating a medical home. So, the medical home
provider communicates and exchanges data with a patient. He or she also
exchanges information with other providers as part of the coordination
function. The third major function is assessing the performance of the medical
home program as a home and assessing the performance of the provider, the
medical home and the medical home specific. Here, there will be data exchanged
between the provider of the medical home and CMS and importantly, there will be
data exchange from the patient to CMS in the form of a CAHPS like survey of
some sort.

And that would be folded into any feedback report that would go back to the
provider. So, let me take these three major functions of data one at a time
beginning with qualification. The initial qualification will require, and let
me just continue to use the NCQA’s PPT tool as my case study here. It will
require ht provider to fill out that instrument, provide that information to
CMS. That process is likely to be much more efficient if it is a web-based
application. So, here’ I’ve got my first data system implication. One
implication that’s specific to a federal program is that sense–and several
speakers have touched on this–let me back up and give a little background
here. Sometimes it’s easy for us to think that oh my goodness, we’re cutting
edge and medical homes are the next big thing.

Well, medical homes are in fact, at least in some provider communities, very
fashionable right now. They are all the buzz. That’s good and that’s bad. The
bad part of that is that it is easy to say that you’re a medical home and it’s
hard to document that you’re a medical home. This poses a challenge to a
federal program, which is to say ensuring the accuracy of the qualification
data calls for a lot of documentation. A lot of verification. Well, it’s
sufficiently onerous to document and verify that every box you’ve checked is in
fact in practice and in use that there’s a burden problem that CMS implementing
program or demonstration has a burden budget and it doesn’t want to blow it’s
entire burden budget on this exercise.

So, we need to find the right spot in that tradeoff. There will also in a
non-going program be a need for periodic requalification – perhaps annual. This
can either done by asking the participating practices to fill the thing out a
gain and perhaps document themselves again, but that would be burdensome.

And alternatively, CMS could adopt an audit approach, auditing a sample of
these medical homes. And/or adopting a performance measurement approach, which
I will come to in this next slide. Okay. So, what we just did was
qualification, and now I’ve jumped to performance. The answer to the question
what do we need data for.

So, this is the way I think of performance measurement in medical homes.
Beginning with clinical quality of care, and here, I’d like to focus on an
ongoing program of CMS, the physician quality reporting initiative, which does
now capture something like $119.00 different measures, most of which are
clinical process measures. CMS is considering developing some outcome measures
and expanding the program to include those.

CMS could require participating medical homes in a Medicare medical home
program to participate in PQRI, it would be a convenient way to collect this
information. Cost savings. Any Medicare program is going to want to measure
cost performance. In the demonstration, there will be some sort of experimental
or quasi experimental design. IN an operating program, that won’t be feasible.
An alternative that is not equivalent, but an alternative approach is to use
efficiency measures. And CMS is currently experimenting and testing efficiency
measures for Medicare.

The third category here is practice structure and structure isn’t quite the
right word, but what I want to do is link this category of performance back to
the qualifications question, which is to say do you have all the necessary
capabilities and are you using these capabilities required to qualify as a
medical home. It could be possible to expand PQRI to include structural
measures designed around the medical home model. They’re not there now, but
that would be possible.

And last, is the patient experience dimension, which a number of speakers
have – I think we have to be very careful never to forget it. I’ve called it
ambulatory CAHPS. Greg called it the physician group CAHPS. But, I’m referring
to the same thing.

So, it would be possible for CMS to require participating practices to
administer or to hire someone to administer such a survey probably based on a
sample of their participating patients. And then this would be folded into any
performance measurement system and into feedback reports.

Okay. The third major answer to what do we need data for is operating a
medical home. And this is one I really want to focus on. The key points here
are operating medical home will require many databases and many data systems.
Require or be facilitated by. I don’t want to be too heavy handed about this.
Much of this operational data may never flow to the federal government. And so
you ask what is the issue for the federal government? The issue is is there a
responsibility in the federal government for setting standards for these data
systems? This will become more clear.

So, it’s somewhat arbitrarily — this is a repeat of the slide of what is a
medical home. And I’ve highlighted the access function of being a medical home.
And this is completely arbitrary. I just picked this function to illustrate how
many data systems are implied by the model.

So, what’s implied here? Well, many of the access related functions covered
in NCQA’s PPC are facilitated by having a fairly fancy appointment scheduling
system. A system that will triage the needs of the patient in determining how
urgently to make the appointment. A system that will schedule as much stuff to
happen in one visit as possible. So as to minimize the number of times a
patient has to come back and so on. A fairly fancy system.

Another function, jumping down to the bottom, having to do with access is
providing off-hours access. This can include an interactive website where some
questions can be answered over the web and some actions can be taken over the
web in off hours. Secure e-mail consultation. Twenty-four hour telephone
access. All of these things require data systems to be implemented.

This is a list of other operational systems that clearly have a data system
implication. And I’m not going to go through them all because it’s late and
we’re tired, but the point here is there are a lot of them, and the data
resulting from these will not necessarily flow to the federal agency. And yet,
for the federal agency to verify that a practice is functioning and operating
as a true medical home there may be a need to set standards and possibly even
certify some of these.

Now, I’m not saying certifying the practice as a medical home. I’m saying
certifying that the e-prescribing system meets some minimum standard of
functionality. And this is not quite as radical as it sounds because CMS is
currently considering certifying electronic medical records systems for its
electronic medical records demonstration.

It’s also considering certifying disease registries as sources of data
flowing into the PQRI program. So, this is not — they haven’t made a decision
yet. I’m not reflecting that, but certifying software is something that is on
CMS’s agenda.

So, to wrap up, adopting a Medicare medical home program perspective. The
model requires lots of databases, lots of systems. Most of which will never see
a federal agency. I think PQRI could be expanded to handle most of the
performance measurement issues.

And lastly, that the federal government should consider a role in setting
standards for at least some of the really critical data systems in operating a
medical home. Than you.

DR. STEINWACHS: Myles, thank you very very much. Let’s open it up for
questions and comments.

MR. REYNOLDS: Myles, on your presentation you mentioned — why is it key
whether this data would or would not flow to the government?

DR. MAXFIELD: I was making an assumption about the interest and purview of
the committee as being really focused on federal data systems. And the point
I’m making is that even data systems that are not federal data systems should
be of interest to this committee.

MR. REYNOLDS: Right. And they are.

DR. GREEN: Terry and Dr. Dobson, could you react to an assertion that I
heard woven into all three of your presentations, how less is more around this
measurement of this stuff about how much data collection will the traffic bear?
How much can you pull out? While you’re taking care of all the folks, how much
data can you collect? You talked about self-populating aspects of it. Terry,
you’ve talked about how you can’t get everything you want, but you’ve got to
get something.

And then Myles, I listened to you talk and you look at your four categories.
If you guys had to tell now, the ten most important data elements that you’ve
just go to get into this to be able to get going, what would they be and if you
don’t have that list firmly in your mind, do you have an idea about creating a
process to find out?

DR. DOBSON: Well, I think the first thing is your claims data. At least in
state Medicaid agencies, we pay the bills. We provide the data for our
community care programs, which they can then use to at least get some
rudimentary population measures. When we started doing disease management, we
picked several key measures, rather than a whole arm’s list because we had to
go into the practice and ask them to collect certain things we couldn’t get off
claims data.

So, again, it’s about administrative burden I think more than anything else.
I think the biggest thing the federal government could do is to get us the
Medicare claims.

DR. McGEENEY: And I think you can integrate the claims data with — there
are quite a few measures you can get out of a practice if they have an EMR,
integrating a lot of the information on that. Even if they don’t, with some
simple manual practice entry and integrating the lab systems and the billing
systems, to get some pretty good data and technology exists is not terribly
expensive. And so, I think if you could integrate some payer data and some
things that can be gotten pretty simply, if it’s a labor burden for the
practice, they are not going to do it. They are just not flat out going to do
it.

DR. DOBSON: I think expanding once you’ve created the system is easier than
giving people a laundry list of a hundred things. It becomes daunting and
again, you’re trying to change the landscape of practices across the country.

DR. MAXFIELD: If I may, the laundry list of performance metrics that I put
on the slide, that’s in a sense — I’m being a little bit rough and ready, but
that’s not the burdensome particularly – the burdensome part that I was
referring to is the qualification step where you may — one would be tempted to
ask for a lot of documentation to verify that you’re actually functioning as a
home and not a house. And we’ve heard a variety of estimates of how much time
it takes to provide all the required documentation to support a PPC instrument
completed. It takes about an hour and a half to two hours to fill the
instrument up. Okay. That’s the eay particular. But the estimates we’ve heard
range from 20 hours to 80 hours to supply the documentation for every piece of
that instrument.

DR. CARR: Thank you for great presentations. Really very, very interesting
and fascinating actually, the interplay. It seems like one of the things we’ve
heard repeatedly today is alignment of incentives. Especially– well, not
especially, every kind of incentive that has come about. And I think that is a
profound message. What impressed me very much in North Carolina, the medical
management teams. I feel like that is the one place where the incentives come
together because the data you have to collect suddenly becomes important to
what you are trying to do. And I also think that it comes very close to what
the clinicians see themselves as what they want to do.

I realize I’m being provider-centric. I know I’ve been accused of before.
I’ll get onto the patient in a second, but as we’re struggling with what are we
going to do? What are we going to measure? Who’s going to measure it? How much
time is it going to take? Who’s going to fill it out? I’m struck by in that
setting of sharing best practices, people come to the table more readily
because there’s a tangible outcome. And so, to not be provider-centered, it’s
informed and directed by the person-centric dimension that I think the whole
medical model does seem to be changing. It’s clearly changing slowly, but we
are getting more person centric. But, I thank you all for your very interesting
insights and your guidance on how we navigate these very challenging and
conflicting waters.

DR. DOBSON: I would just add that not all incentives have to be economic.
Having help certify is an incentive, but may not be a direct economic
incentive. Providing practice incentive is an incentive. Providing additional
resources to a practice or a patient. Again, if you mandate patients into this,
it will never work. It has to be a value-added proposition, where people think
this is the better way to go and choose to participate. Patient and physicians.

DR. STEINWACHS: Nancy, I saw you raise your hand.

DR. BREEN: I was going to initially ask this question just of Allen Dobson,
but I think I’d like to hear Dr. McGeeney’s response to it, too. I was really
struck as you were talking about North Carolina. I think this is a Medicaid
program, but I think you’ve leveraged a lot of funds. And maybe assistance,
technical assistance and help from other sources as well in order to get the
job done or the incentive structure. You’ve put this all together in a really
creative way. Could you talk a little bit more about that? About what kinds of
monies are coming together because it’s not all Medicaid money, is it? And then
you’ve provided assistance and the hours needed to be paid for, or may they are
volunteers, but all of that work needed to get done in an organized fashion and
timely fashion.

DR. DOBSON: I think if you’re building a community system or your’
transforming a healthcare system, you’ve got to get away from even the solid
thinking of the funder. We did build it on Medicaid because that’s what we had
at the time, but it was a confluence of private foundations and some public
foundations that actually put some seed money in to get this going.

Medicaid was the first step, but we also had in-kind help from local
communities and hospitals as we tried to build this. What we found though is if
you go into a practice and change it for one payer, they don’t change their
practice behaviors just for Medicaid asthmatic patients. You really are talking
about a practice change at the local level, which is why some of our networks
got into doing the uninsurer. If I could just have a care manager, I would take
care of the uninsured patients for free if I could have someone help me get
them through the system because it shouldn’t take me more time to take care of
someone for free than it does for someone I’m getting paid for.

DR. BREEN: So, where’d you get the care manager? I mean, is this just your
personal charisma? How did you pull all this together?

DR. DOBSON: Well, again, I think that we had private foundations who helped
fund, and in particular —

DR. BREEN: Did they come to you or did you go to them?

DR. DOBSON: Both. We have a unique alignment of people wanting to help and
that’s why — our AHQ system is a partner. Rather than going and hiring more
staff to do chart audits for our communality care audits, we went to a resource
that was already in our state with our area health education centers in all
states and said we would like you to do our chart audits. We paid the AHICs to
do chart audits. It was a natural next step to say if we want help transforming
practices and help giving the extra help to set up registries to train their
staff, that we would use existing resources.

So, it’s why you see one network being one network or one set of practices.
It’s because we try not to create something new. We try to leverage existing
competence resources. So, one community’s health department may be a provider
and another one, it provides the case managers.

DR. BREEN: And Terry McGeeney, how did you do it because you pulled off
something similar?

DR. MCGEENEY: I’ll just echo a little bit first what he said. The care
manager’s concept really does work, but the key is that those care managers be
connected back to the medical home. That’s why a lot of case management today
hasn’t worked that well because it fragments the system. And I think that’s
what we are going to have to guard very carefully against. And that’s where,
again technology and information will really support that. But, the care
management model does work. And it doesn’t have to be a physician doing all
that, but it must somehow be created to the medical home. The second comment
from what Allen made. All incentive and support doesn’t have to be financial.
Helping practices collect data. Help practices store data in a language that
can be moved. Help practices get population-based registries is an extremely
valuable tool – probably more than money in many environments.

Back to the economic issue for us. We had a unique situation because the
American Academy of Family Physicians gave us a big bucket of money and we were
totally funded by them.

DR. STEINWACHS: Debbie, you were next, was this on the same thing? Then
Harry and then Larry.

MS. JACKSON: That was the same question I had. I did hear from you Dr.
Dobson a statement less about the physician as about the physician staff. Was
that something you actually heard?

DR. DOBSON: It’s a statement of this is team sport, and it really involves
around what dos the patient need? Because a patient, particularly one that has
medical illnesses or needs continuing care interacts with the healthcare system
in multiple places. And it really is about making sure the staff and the
medical home work correctly. You can’t rely totally on the physician to make
this happen. So, if you really want a system to change in a physician’s office,
you have to have the nurse, the office manager, the front office folks. If you
want a community system change, you have to engage more than just one agency,
one hospital. You really have to get everyone around the table and refine how
that patient experience is a system. Just take your own experiences with
relatives or yourself and walk through the system and understand how that
works.

I heard someone say their experience in the hospital. Not that often, but I
still have hospital privileges and we still operate a hospital service. And
I’ll tell you that our job is translation. It’s translating and making sure
that none of the balls get dropped. And then it’s the handoff back home. That’s
where all the action is.

DR. STEINWACHS: Harry and then Larry.

MR. REYNOLDS: Nancy, playing off of your point. Because of what Dr. Dobson
and they are doing in North Carolina and because of their relationship with
physicians and because of what they’ve done. And I think all of us on this
committee have struggled with adoption of anything in a doctor’s office. And
who is their advocate and how do you group them up. And we’ve done this. We’re
all in the middle right now. We’ll be hearing Wednesday about the national
provider ID, which is still struggling to happen one doctor at a time, one site
at a time.

But, for example, in North Carolina, our company is advocating e-prescribing
for every doctor in North Carolina. They are the conduit to deliver it. So, you
talk about funding sources. If we believe that e-prescribing and we want to
raise the boats for everybody and they are the conduit who has already set up
the medical home, already work in the process. Already knows how to deal with
offices. Already knows what they can do. We’re in those discussions right now.
Not pre-announcing anything. Just talking about the fact because now we’ve got
someone to talk to that’s got 3500 doctors.

We could go out and talk to 3500 one at a time and you’re dealing with 3500
boats. Some of them never leave the dock. And so, once this gets going and once
you show these relationship, then there are other funding sources, other
capabilities that become multi-payer that raises the boat for everybody and
start making a difference and that makes it incredibly more attractive to
anybody who wants to get in and make a difference because we are dealing with
one set of people for 3500 doctors, not 3500 doctors one at a time trying to go
meet their office staff and do everything else.

And oh, by the way, that person–once you do e-prescribing or
something–that person is going to actually watch what’s happening. So, then
you get a synergy where it has nothing to do with who’s who. It has to do with
how do we make a difference in North Carolina. That’s a dramatic next step.

DR. DOBSON: Leveraging the pharmacists who work for our networks to go get
the other pharmacists who are not currently using e-prescribing so that you can
move a community.

DR. GREEN: I wanted to ask Chris Nohrden if he wouldn’t mind reacting to
what he heard from these three gentlemen.

MR. NOHRDEN: Some of it I did plan on talking about tomorrow and it
addresses the whole issue of data integration and particularly in the smaller
practices where it is really becoming an issue with a lot of the state and
community pilots. If I can hold the question until then and give me overnight
to think about it.

DR. GREEN: Let me narrow it substantially. Did you find this encouraging or
discouraging on a multiple choice test?

MR. NOHRDEN: I find it encouraging.

DR. STEINWACHS: Leslie.

DR. FRANCIS: Can I follow up with a version of that. I heard the first
presentation as the glass half empty. That’s Terry’s. And the second is the
glass is half full. That’s Allen’s. And I want to ask is part of that was that
you were, in some respects, looking at different levels? You were looking more
system.

DR. DOBSON: I was glass half full because I’m not the Medicaid director
right now. I don’t have to worry about the budget.

DR. FRANCIS: I wanted to ask whether that seemed accurate to other people or
to the two of you. And if so, if you had any thoughts about why it might be so?

DR. McGEENEY: I structured it that way because I wanted to drive home the
point how hard this stuff is. And it kind of goes back to even how hard it is
to measure it. It is really really hard to do and it’s easy for us to sit
around and talk about, but it’s very hard to do. So, I think that was my theme.
On the other hand, having had practices that have gone through it, they are
saying the yare finally enjoying medicine again. I’m finally taking care of
patients – which is what I went into primary care for.

So, when you ask the providers that have actually done it, it’s more than
half full. For us that are out there trying to move the needle, it’s probably
still half empty.

MR. LAND: I heard community resources being brought to the table, but I
didn’t hear anything about public health. And I’m just wondering if public
health has a history of registries? Has a history of ensuring that patients are
taking their medications and so forth. So, I was wondering if public health was
one of the resources brought into it?

DR. DOBSON: They are required in our networks as a partner. So, that was
early on that we understood that, particularly for the Medicaid program, but
really overall having the Public Health Agency as one of the required partners
in any of these not for profits. So, I would say that in our networks, they
carry multiple roles from provider. Some of them actually provide the care
coordination services to the entire network. Some of them are the lead agency
in our networks.

Others take a more passive role and have gone to being the provider of
patient information and are dealing with some of the literacy issues. So, there
are some interesting things the health departments are doing, but they are a
key player.

DR. McGEENEY: We spend a lot of time focusing on collaboration of care and
teamwork. And one of the questions we always ask our community resources. And
one of the things we always work with is practices to identify what the
community resources are. And then we ask them how they are engaging them.
Having said that, one of the biggest disconnects is between community resources
and private practices. You never know what immunizations a patient got and when
they got them if you are in private practice and so, moving that information is
a real challenge.

Dr. STEINWACHS: Any other questions or comments? Well, I really want to
thank Terry, Allen and Myles. It’s been a great sessions. I thought it was at
least two-thirds full by the time I was done. You can see we’re into metrics.
Very good. So, thank you. Thank you very much.

Next on the schedule, we do have some time if there is anyone for public
testimony or comment. Those who aren’t around the table or those who are at the
table who are not members of the committee or scheduled to present.

So, if anyone would like to, we certainly welcome that.

Agenda Item: Public Testimony

MS. PARTRIDGE: Before we lose Dr. Dobson, I want to set the record straight.
I think I said in my testimony earlier this afternoon that you are still a
gatekeeper program. And he tells me that you are not a gatekeeper program
anymore. Is that right? It is more akin to the concept that CMS is talking
about with a voluntary–

DR. DOBSON: We grew out of the gatekeeper concept from a federal — I don’t
know if we are or not. We don’t operate as one.

MS. PARTRIDGE: IN other words, you’re primary care provider doesn’t have to
authorize access to the specialist?

DR. DOBSON: The specialist only has to have the provider’s number to get
paid. They all have them. So, we don’t enforce that part of it. And patients
can change their primary care doctor at will. For patient access, again, we
found that for women and children we left that program in tact. Aged, Blind,
Disabled are obviously not a mandated program. So, we operate it as a
non-gatekeeper model.

MS. PARTRIDGE: The reason I thought that was important is that your cost
savings projects are based on what you’re doing right now. In other words, a
gatekeeper is not a prerequisite?

DR. DOBSON: No, in most of our cost saving-driven, and you can see that in
our report for decreased hospitalizations and ER visits, advanced access, it’s
good policy. If you want people to have access after hours, what we did is we
said anything after five and on weekends is considered an after hours visit and
we pay an extra fee to incent the docs to stay open. To see work-ins in
Medicaid and the pediatricians do. So people can walk in and be seen in a lot
of areas of the state. And we’re seeing our ER rates drop for that.

DR. STEINWACHS: Is there anyone who would like to say something that hasn’t
had a chance?

DR. BREEN: Well, I’ll move to North Carolina for healthcare.

DR. BETHELL: Don, is it okay if I — there were a couple of things that I
wanted to make sure got taken away. I think it’s really common to think of
patient input as satisfaction information. I think it’s really important to
recognize that there aren’t really very many — none of the tools that I’ve
presented have any questions about satisfaction on them. And it is true that
people can be very satisfied and get bad care and be unsatisfied and get good
care. And that’s the main reason. So, it’s just important for you to know that
the tools that are out there are asking about concrete experiences related to
clinically recommended aspects of care, including things like self-management
and shared decision making and access. So, I think that’s important to
recognize and also the issue about children, especially children with special
needs.

As much as we care about them, they are still a really small proportion of
dollars even for Medicaid. And so, to keep on the docket children and youth may
be hard because of that. And it’s an economically driven world. But I would
just like to put a plug in for that because I think the potential benefits in
the long run are well worth it.

DR. DOBSON: I agree with you, but if you take the larger view, children with
special health care needs belong to families who also are citizens and members
in the community and the impact on the family and the community goes beyond
taking a single line item in the budget. And that’s really true. There’s a lot
of other budgets where the social supports and stuff. So, I think that’s
something to remember when you look at any particular population. Not just to
consider the single siloed budgetary item.

DR. BETHELL: And it’s about one and four families that qualify on a pretty
stringent criteria for having a child with a special healthcare need. It’s not
a small proportion.

DR. BREEN: One in four families with children or one and four families?

DR. BETHELL: One in four families with children. Excuse me. In lower income
Medicaid and it’s about 21, 22 percent in the higher income. So, it’s a good
chunk of families. And that’s a pretty high bar for quicker identifying such
children.

DR. DOBSON: One thing I didn’t realize until I was a Medicaid director was
if you look at what is a disabled Medicaid recipient before they are a disabled
Medicare recipient, they are almost always uninsured. And what is a dually
eligible Medicare/Medicaid patient before they ere dually eligible, they are
usually elderly and have gotten poor enough from their healthcare to become
dual. So, we have to remember that we think in silos, but for the patient, it
really is much different. I just want to say for special needs kids, you have
to think about the family and the community they live in. The impact is much
beyond that single budget.

DR. STEINWACHS: Thank you Allen, and thank you Christina. We have a last —
Leslie, yes?

DR. FRANCIS: I actually had a question for Christina that I didn’t ask
before, which is whether when you’ve been thinking about adolescence, whether
the design looks really different. And I had the confidentiality question
behind that, and I just wanted to know if you had anything to say about that
quickly?

DR. BETHELL: Yes. First of all, one thing I didn’t say was that the medical
home measures I presented are very correlated with many other aspects of the
quality that we also measure, including health outcomes in the school and many
other things. So, there’s much to be mined in there.

And when it comes to adolescence, private and confidential care is
absolutely essential, and there are some aspects of medical home that there are
really not suited to share about, but there are other aspects that they are
really really better suited to report on than parents. And we have a pretty
good — I would say we are about 60 to 70 percent there wit the current
measures we have. And it’s just a matter of putting them together with another
round of testing and development. The private and confidential is absolutely
key for adolescents.

Agenda Item: Committee Discussion

DR. STEINWACHS: Any other questions, comments? We put a few last minutes
here for sort of end of the day conversation for the committee about what are
the take aways or things we ought to summarize or think about from today’s
session. Is everyone worn out? Justine? Harry?

MR. REYNONLDS: No, again, you started off the conversation by thanking
everybody. This has been a great panel. Incredible learning in a half a day and
we still have a whole day to work with it. And I think it is very very
thoughtfully put together. And many differing perspectives and I think it’s
really going to move everybody forward. I wish more members of the full
committee had the opportunity to hear a lot of this because I think regardless
of whether it turns out to be exactly the medical home, it sure does open all
the discussions about where everything might end up. And I think that’s the
thinking that we are going to be facing over the next couple of years, figuring
out how to move the ball forward. So, thank you. Thank you to everybody that’s
done it.

DR. CARR: Yes, and I would echo that again. I also think that, as I said,
just a kind of preliminary themes, one is the incentives and another is the
tempo. We’re hearing about some very exciting things and we’re hearing about
some very thoughtful prospective analytics. And trying to strike the balance
between achieving the benefits while doing it in a thoughtful, durable,
understandable fashion, I think is a very formidable challenge but one we might
want to think more about.

MS. GREENBERG: In that regard, I guess Myles’ assumption that we kind of
disabused him of that if it wasn’t federal data, we weren’t interested in it.

DR. STEINWACHS: We love all data.

MS. GREENBERG: Yes, we’ll have to send him the 50 year anniversary. We have
to educate him a bit about the NCVHS and how we poked our head in whether we
were asked to or not. No, I mean, I thought his presentation was outstanding
and they were all excellent and I want to echo the thanks to leadership here
and to Matt. I mean, I have been involved in planning a lot of hearings over my
day. Mom Greenberg here, but it was as good a process as I’ve ever seen.

And then you always say well the proof will be in the pudding, but so far
the pudding has been really exciting. But, I think regarding the whole
standards issue, which of course, is one of my strong interests, is that one
way, of course, to do this would be to set standards and then certification
standards and then go the whole thing would be to have this whole medical home
concept be a use case for the AHIC or the post AHIC, and of the health
information technology standards policy, but I think — I wasn’t there, but I
was told when they revisited this at their last meeting, they felt that there
was not enough — that this was too new, too developing, et cetera. Too much in
motion to really develop a use case and standards for it. But, it’s something
that I’m sure they will revisit. I mean, there was a lot of interest
apparently. I don’t know. Debbie, you were there. Do you want to say anything
more about that?

MS. JACKSON: (Responds off microphone.)

MS. GREENBERG: So, it’s something for us to think in terms of — I mean,
there is a process there. It’s just that it wasn’t considered ready yet, but it
could be in the future.

DR. QUINN: One set of thoughts that I had is the PPCPCMH assessment tool and
probably the one that CMS is going to adopt rates medical homes on level one
through three. One being sort of the good enough medical home and three being
that high functioning one that has all of the bells and whistles that Myles
listed at the end of his presentation.

Accordingly, a level one medical home would probably receive one level of
additional reimbursement. Two, another level and three, more. And ultimately, I
think one of the key questions to decide here is whether one is good enough and
how you set the — you know, you get what you pay for I guess. And how much
better, as you measure it is a level three or high functioning medical home
versus one. And are we happy as those who pay for it. And figure these things
out to have organizations stuck at one. And then say divide it up at some
level. Or is there a three and maybe is there a four in the future?

That incremental value or benefit measured and progressing along I think is
really that key thing. And that will lead to a lot of complicated questions
about, if a registry is good enough, we can figure out a data standard for a
registry. Or, if you have to add in an exchange between organizations and
exchange of blood pressure data with consumers in their homes, then you’re
talking a whole ‘nother ball of wax.

DR. STEINWACHS: Larry, I saw you tip your head this way. Did you want to say
something or not?

DR. GREEN: No, I’m listening.

DR. STEINWACHS: Anything else you’d like to share at this time? It’s been a
great day. I agree.

DR. GREEN: In anticipation of tomorrow, something that happened for me this
afternoon that I did not anticipate was I think that this set of presentations
the way they happened to come together and be presented really did provide the
committee with essential background for being able to think about the data
model. And the fact that we’ve got some folks coming tomorrow to talk about the
data model is something that excites me. And I think I’d like to forecast that
that’s going to be interesting, and it might even be important. And I want to
ask all of you to listen hard and help think through what the implications of
the patient-centered medical home are for a data model. And then in reverse,
once you get to thinking about that data model, what are the implications for
measuring these characteristics that Myles laid out so well about the different
measures.

That strikes me as being close to the pay dirt for the population
subcommittee of NCVHS. If we can get our mind around that just a bit tomorrow,
it seems to me that perhaps it would have been worth the effort.

MR. REYNOLDS: And one other thing I would add to that is as we listen
tomorrow and we talk about data models and the whole flow is how we would want
to possibly engage other subcommittees on this subject of medical home. So, for
example, when he mentioned the data model, well, with the current standards
that we have right now out there don’t capture the data that’s needed, then it
isn’t going to magically appear. Leslie has brought us some discussions on the
privacy. We’ve looked at privacy through many many filters and not necessarily
the filter of the medical home, which may have that doctor going further than
we would have normally assumed that a doctor. We’d have gone with a one doctor,
one patient relationship. Not the doctor being in charge of the overall care.

So, those are the things that I would also like to make sure that we
extrapolate as we think about it because populations will have the ball on this
subject, but on the other hand, if we don’t bring this stuff along through some
of the other opportunities that we have, the same thing with quality and data
that we’re going to be looking at and so on. If we don’t bring it forward to
make this picture actually play out, then I think that’s another thing on a
subject this big that we need to figure out how we are going to adjudicated it
in general. And possibly, that’s populations leading it or however we do it.
So, thanks.

DR. STEINWACHS: Excellent point. We start at 9:00 tomorrow morning. Nine
makes it a little bit easier. I understand.

(Whereupon, the meeting adjourned at 5:50 p.m.)