Two kinds of talks

1. Understanding the Patient-Centered Medical Home: What Is It? What Can It Offer Patients, Physicians, and Those Paying for Health Care?May 29, 2010 Alabama ACP Chapter Fred Ralston, Jr. MD, FACPPresidentAmerican College of Physicians Fayetteville Medical Associates, PC Fayetteville, Tennessee

2. Two kinds of talks • Emotional – from the heart but without the data to back it up • Data filled slides that put all to sleep and while evidence-based are met with skepticism by those who feel they may not be relevant to those practicing in “the real world” – private practice or academic practice which is stressed by the same payment system • I hope to show you why as a practicing internist I am so excited about the medical home and also that we have the data to back this up

3. From the heart • Internal medicine – both general and subspecialty is a highly rewarding professional career – I would argue among the highest callings possible • General internal medicine and many subspecialties face tremendous threats to survival without improved payment • Those subspecialists who like the current payment system need to know that it is unsustainable and will melt down if the cost curve is not bent

4. From a self-professed health policy wonk • I am convinced that there is no way possible under the current payment model to rebalance primary care through modifications to the RBRVS alone • There is no traction to pleas asking for higher payments for primary care using the current delivery model • There will be continued unfunded or semi-funded mandates or expectations involving but not limited to quality improvement and reporting

5. From a self-professed health policy wonk in private practice • I am sympathetic to internists who say that the patient-centered medical home is what they have been doing for twenty years • Many practices are close but require documentation and others have further to go • With current trends in workforce, practice overhead, if there is no fundamental change in payment private practice of general internal medicine will only exist in subsidized environments

6. Subsidized environments? • Hospital ownership of practices • Integrated groups pulling in revenue from ancillaries and other specialties • Those offering an insurance product or gain sharing with insurers

7. Recruiters Delight • (A) Physicians without subsidy often are barely able to meet overhead and are left with limited salaries • (B) Physicians who are paid a salary that truly reflects their contribution often receive a salary $80,000 or more in excess of those in (A) • It is easy for recruiters to do well receiving a fee moving doctors from (A) to (B)

8. Unintended Consequences • (A) Physicians without subsidy often are barely able to meet overhead and are left with limited salaries • (B) Physicians who are paid a salary that truly reflects their contribution often receive $80,000 or more higher than those in (A) • Doctors in (A) are often key elements of care in rural , inner city and underserved areas • This transfer of talent could further add to disparities in health care

9. Unintended Consequences • Smaller practices with seasoned veterans may close before they can attract new physicians to provide care • It would be wise to bring a new generation to learn the art of medicine from those who have decades of experience • Time is short • We need to increase the pipeline for primary care before these potential mentors leave practice

10. Alignment of incentives • Hospitals, unless the process changes from previous efforts, are not well suited to be nimble in running medical practices • Some of the first savings to be gained from improved medical practice is savings from hospital admissions – that runs counter to financial pressures on hospitals • If general internal medicine (and other primary care) is reimbursed according to its true worth rather than as a loss leader it allows us to try various models of practice organization

11. From someone in private practice GIM since 1983 • Revenue is flat • Less free time and more hassles • Expenses rise relentlessly • Over the years experts have regularly presented a new idea which didn’t work to save or enhance primary care

12. Initial response to medical home • I don’t have the time to set one up • I don’t have the money and resources to set up a medical home • It’s just another idea that will end up not working • Notice the I (or even we referring to my physician partners)

13. Why have I changed my mind and started to set one up? • I have been hearing great things from practices large and small who have started this process • Someone else is paying much of the start-up costs • There is a full time employee (not paid out of our limited revenue) to help us transform our practice • The patient-centered medical home will provide a platform to deal with some ongoing issues related to continuous quality improvement

14. Preliminary Results Indicate These Trends • Happier patients • Happier staff • Happier doctors • Lower cost • Higher quality • Helps practices do many of the things we are expected to do now but become easier in a team based approach with the proper resources

15. Why isn’t this just another passing fad? • Aligns incentives toward improved care • While the payment levels are not yet finalized initial levels for general internal medicine are much higher than current practice revenues allow • Best hope to provide attractive practice opportunity for new doctors • Provides proper resources to free up physicians for direct patient care • Team based approach provides opportunity to use scarce health professionals in evidence-based ways to provide cost-effective care

16. Goals today • Review quality and cost issues in the US • Make the case for primary care being associated with lower costs and better outcomes • Explain the Patient Centered Medical Home • Make a case for why we need it • Try to make the medical home seem less frightening to internists in a variety of practices

17. What is primary care? • The Institute of Medicine describes primary care as "the provision of integrated, accessible health services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." • ACP also notes that the hallmarks of primary care are "first contact care, continuity of care, comprehensive care, and coordinated care" of the whole person.

18. What is not comprehensive primary care? • Doc in the box • Nurse in the box • Primary care for ________________ Fill in body part or system • Remember that the hallmarks of primary care are "first contact care, continuity of care, comprehensive care, and coordinated care" of the whole person.

19. Changing Demographics, and the Unsustainable System.“The Perfect Storm”

20. EQUITY: COORDINATED AND EFFICIENT CARE Exhibit 42 Went to ER for Condition That Could Have Been Treatedby Regular Doctor, Among Sicker Adults, 2005 Percent of adults who went to ER in past two years for condition that could have been treated by regular doctor if available International comparison United States, by race/ethnicity, income, and insurance status GER=Germany; NZ=New Zealand; UK=United Kingdom; AUS=Australia; CAN=Canada; US=United States. Data: Analysis of 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults; Schoen et al. 2005a. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

21. Changing demographics Statement of Peter R. Rosa. Director, Growth in Health Care Costs, Congressional Budget Office, before the Committee on the Budget United States Senate, January 31, 2008 www.cbo.gov/ftpdocs/89xx/doc8948/01-31-HealthcareSlides.pdf

22. The Increasing Elderly Population Source: U.S. Census Bureau, “U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin,” <http://www.census.gov/ipc/www/usinterimproj/>

23. Chronic Health Conditions 120 Million Americans (45%) Have at Least 1 Chronic Condition 60 Million Have Multiple Chronic Conditions 83% of Medicare Beneficiaries Have 1 or More 23% of Medicare Have 5 or More By 2015, 150 Million Will Have at Least 1 Chronic Condition Sources: Wu and Green, Projection of Chronic Illness Prevalence and Cost Inflation; RAND Health, Oct. 2000and GF Anderson, Medicare and Chronic Conditions. Sounding Board. N Engl J Med. 53(3):305-9.

24. Physician Workforce The Supply of Primary Care Physicians Will Not Keep Pace with the Aging Population Already Anecdotal Evidence of Shortages As the Population Over Age 65 Increases More Doctors Will be Needed High Student Debt and a Dysfunctional Payment System are Deterring Physicians from Primary Care Careers The Physician Workforce Is Also Aging: 250,000 Active Physicians Are Over Age 55 Sources: ACP, The Impending Collapse of Primary Care, 2006, http://www.acponline.org/hpp/statehc06_1.pdf ACP, Creating a New National Workforce for Internal Medicine, 2006 . http://www.acponline.org/hpp/im_workforce.pdf

25. USA (and Canada) have LONG WAIT Time to See Doctor When Sick or Need Medical Attention Last time you were sick or needed medical attention, how quickly could you get an appointment to see a doctor? Percent of adults Percent of adults reporting 6 days or more Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. 2005a). 25

26. USA: MORE ERRORSDeaths Due to Surgical or Medical Mishaps per 100,000 Population in 2004 b b b a b b a2003 b2002 Source: The Commonwealth Fund, calculated from OECD Health Data 2006. Cylus J and Anderson GF. Multinational Comparisons of Health Systems Data, 2006 J. Cylus and G. F. Anderson, Multinational Comparisons of Health Systems Data, 2006 (New York: The Commonwealth Fund, Apr. 2007).

27. Lesson: The best payment systems recognize the value of care coordinated by primary care physicians Belgium United Kingdom • Effective payment systems: • Provide adequate payment for primary care services • Create incentives for quality improvement and reporting • Recognize geographic or local payment differences • Provide incentives for care coordination Canada Denmark Germany United Kingdom Denmark Netherlands

28. Lesson: High performing systems invest in HIT, have uniform billing, and lower administrative costs Germany Canada Taiwan United Kingdom and most others • Adoption of a uniform billing and electronic processing of claims improves efficiency and reduces administrative expenses • An inter-operable health information infrastructure can enable physicians to obtain instantaneous information at the point of medical decision-making and enhance electronic communications among treating health professionals Denmark Taiwan Netherlands

29. Why is Primary Care Important? • States with higher ratios of primary care physicians to population have better health outcomes* • Supply of primary care physicians associated with an increase in life span & reduced low birth-weight rates* • In both England and the US, each additional primary care physician per 10,000 population (a 12-20% increase) is associated with a decrease in mortality of 3-10%, depending on the cause of death** *Starfield, B., et al: The Milbank Quarterly 2005; 83:457-502 **Gulliford, J Public Health Med 2002; 24:252-4

30. OECD = Organization for Economic Cooperation & Development PYLL = Potential years of life lost

31. Primary Care Associated with Decreased Costs • According to the Center for Evaluative Clinical Sciences at Dartmouth, for patients with severe chronic diseases, those who live U.S. states that relied more on primary care have: • Lower Medicare spending (inpatient reimbursements and Part B payments) • Lower resource inputs (hospital beds, ICU beds, total physician labor, primary care labor, and medical specialist labor) • Lower utilization rates (physician visits, days in ICUs, days in the hospital, and fewer patients seeing 10 or more physicians) • Better quality of care (fewer ICU deaths and a higher composite quality score Dartmouth Atlas of Health Care, Variation among States in the Management of Severe Chronic Illness, 2006

32. Where Have All the Doctors Gone? By: Patricia Barry | AARP Bulletin print edition | - September 2, 2008 • The experience of one small-town primary care doctor sums up what is happening. Fred Ralston Jr., M.D., is an internist in Fayetteville, Tenn., where his family settled 120 years ago. …. • His world is totally different now from when he started practice in the 1980s, he says. “There were plenty of primary care physicians, and we had time to see and get good relationships with patients,” Ralston says.

33. Where Have All the Doctors Gone? By: Patricia Barry | AARP Bulletin print edition | - September 2, 2008 • Despite his own job satisfaction, Ralston doesn’t blame young doctors for not going into primary care when they can choose other specialties with defined hours, higher salaries and less hassle, especially when they have huge debts from school and young families. • “Every neighborhood in the country is one doctor away from a crisis,” he says. “If I go away and my 2,000 patients are let loose on the market, there are not enough doctors to absorb them.”

34. NBC Nightly News with Brian Williams July 14, 2009 Doctors Wanted • 3rd year medical student considered family practice until he actually worked in a clinic trying to do preventative care and get to know a patient in 15 or 20 minutes – I questioned my ability to serve my patients the way I wanted to • Family Doctors $190,000 ** (Recruiters often move primary care doctors from practices netting much less than this to salaried jobs where ancillaries or a sponsor is able to raise the income to this level – often adding to disparities in physician supply.) • Radiologists $424,000 • Spinal Surgeons $611,000

35. ACP’s proposals for a high performing health care system • U.S. should support primary care with payment and workforce policies • Set specific targets for producing generalists and specialists and enact policy to achieve such targets • Pay for care coordination, prevention, and quality improvement by primary/principal care physicians • Pay primary care physicians at a level that is commensurate with demonstrated value (better quality and less cost) • Fund care provided through a patient-centered medical home

36. Goals • Don’t stifle innovation but use new technology and medications wisely with comparative effectiveness studies • A balanced physician workforce where patients get the right care from the right physician or provider at the right time • Hassle factors reduced for overburdened physicians and other providers by common forms and platforms for paperwork that limit time to providing clinical info not doing busy work

37. Patient-Doctor Relationship A long-term comprehensive relationship with your Personal Physician empowered with the right tools and linked to your care team can result in better overall family health…

38. How Connected Are You to Your Primary Care Physician “Not surprisingly, those patients with the strongest relationships to specific primary care physicians were more likely to receive recommended tests and preventive care. In fact, this sense of connection with a single doctor had a greater influence on the kind of preventive care received than the patient’s age, sex, race or ethnicity.” How Connected Are You to Your Doctor? Patient–Physician Connectedness and Quality of Primary Care Steven J. Atlas, MD, MPH; Richard W. Grant, MD, MPH; Timothy G. Ferris, MD; Yuchiao Chang, PhD; and Michael J. Barry, MD 3 March 2009 | Volume 150 Issue 5 | Pages 325-335

39. YET Yet…Most patients unable to identify their physicians, survey finds 75 percent of the patients were unable to name a single doctor assigned to their care. Of the 25 percent who responded with a name, only 40 percent were correct-- Karen Barron, New York Times, January 29, 2009 DR. WHO? Source: http://www.nytimes.com/2009/01/30/health/30patients.html?ref=health Arch Intern Med.2009; 169: 199-201.

40. The New Yorker: The Cost Conundrum June 1st 2009 by Atul Gawande • When you look across the spectrum from Grand Junction to McAllen you see A threefold difference in the costs of care— • You come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

41. The New Yorker: The Cost Conundrum June 1st 2009 by Atul Gawande • The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen. • The foundation of this is at the Micro level someone has to be Accountable for your care -- that is the PCMH in most of the civilized world !!!

42. The PCMH concept advocates enhanced access to comprehensive, coordinated, evidence-based, interdisciplinary care Medical Home Care Today’s Care My patients are those who make appointments to see me Our patients are those who are registered in our medical home Care is determined by today’s problem and time available today Care is determined by a proactive plan to meet health needs, with or without visits Care varies by scheduled time and memory or skill of the doctor Care is standardized according to evidence-based guidelines I know I deliver high quality care because I’m well trained We measure our quality and make rapid changes to improve it Patients are responsible for coordinating their own care A prepared team of professionals coordinates all patients’ care It’s up to the patient to tell us what happened to them We track tests and consultations, and follow-up after ED and hospital Clinic operations center on meeting the doctor’s needs An interdisciplinary team works at the top of our licenses to serve patients Source: Adapted with permission by IBM from Daniel F. Duffy, M.D.

43. The Patient-Centered Primary Care Collaborative:Examples of broad stakeholder support and participation Providers 333,000 primary care Purchasers – Most of the Fortune 500 • IBM • General Motors • ACP • AAP • FedEx • General Electric • AAFP • AOA • Pfizer • Merck • ABIM • ACC • Business Coalitions • ACOI • AHI • Wal-Mart 80 Million lives The Patient-Centered Medical Home Payers Patients • NCQA • AFL-CIO • BCBSA • Aetna • National Partnership for Women and Families • Humana • United • HCSC • MVP • CIGNA • Foundation for Informed Decision Making • WellPoint • Kaiser • SEIU

44. Why the Patient-Centered Medical Home? • The Patient Centered Medical Home creates a framework for change • The Patient Centered Medical Home creates a common language for change • The Patient Centered Medical Home creates an opportunityfor change • The Patient Centered Medical Home aligns paymentwith the added valve and therapeutic relationship.

45. While other approaches have addressed some PCMH factors, none has addressed them all Source: IBM

46. On the PCMH -- you than build the “Caring VILLAGE” • Collaborative Care • Coordinated Care • Shared Responsibilities • Community Resources • Team Care in and outside the practice • Interoperable Technology • Shared vision/alignment • Education

47. Pilots: BCBS North Dakota, Marillac Clinic (Chicago) • 6% decrease in hospital admissions • 24 % decrease emergency room • $500 per member per year savings Marillac’s Integrated Care Patients (PCMH)

48. Pilot: Geisinger Health System

49. Results: Clinical Process Metric Improvement HbA1c Testing January 2007 November2007 Permission from Horizon Blue Cross Blue Shield and Partners in Care, Corp.

50. Pilot with best overall data Group Health’s experience in a prototype clinic suggests that primary care enhancements, in the form of the medical home, hold promise for • Controlling costs • Improving quality • Better meeting the needs of patients and care teams.