Patient Centered Primary Care Collaborative July 16th Stakeholder s Working Meeting Public and Private Initiatives: Ad

1. Edwina Rogers Executive Director Patient Centered Primary Care Collaborative 601 Thirteenth St., NW, Suite 400 North Washington, D.C. 20005 Direct: 202.724.3331 Mobile: 202.674-7800 erogers@pcpcc.net Patient Centered Primary Care CollaborativeJuly 16th Stakeholder�s Working MeetingPublic and Private Initiatives: Advancing the PCMH 1

2. 20 May 2012 2 Boehringer Ingelheim:Corporate Overview

3. 20 May 2012 3 Boehringer Ingelheim: Our Interest in Healthcare Reform Comprehensive Health Reform Could Increase Coverage and Access to Care Uninsured Americans face obstacles in obtaining health care and suffer adverse health outcomes, so we support the goal of extending coverage to the uninsured The BI Cares Foundation demonstrates our commitment to helping the uninsured; in 2008 alone, the Foundation served 53,000 patients and provided more than 126,000 prescriptions We are committed to improving the quality of life for patients through ongoing and innovative research

4. 20 May 2012 4 Boehringer Ingelheim: Our Interest in Healthcare Reform Comprehensive Health Reform Could Increase Coverage and Access to Care Uninsured Americans face obstacles in obtaining health care and suffer adverse health outcomes, so we support the goal of extending coverage to the uninsured The best approach to providing health insurance is through private sector competition, which offers consumers choices of health benefits and controls costs For example, Medicare drug benefit program successfully delivers access to pharmaceuticals at lower than expected costs due to competitive market forces The program consistently demonstrates overwhelming satisfaction from its beneficiaries (nearly 90% satisfaction rate) We are committed to improving the quality of life for patients through ongoing and innovative research The BI Cares Foundation demonstrates our commitment to helping the uninsured; in 2008 alone, the Foundation served 53,000 patients and provided more than 126,000 prescriptions

5. The Big Picture: Focus on Health Care Reform Carolyn M. Clancy, MD Director Agency for Healthcare Research and Quality PCPCC Stakeholder�s Working Meeting Washington, DC � July 16, 2009

6. Focus on Health Care Reform 21st Century Health Care Comparative Effectiveness Research Revitalization of Primary Care

8. Health Care Reform in the Current Economic Environment

9. More Say Reform Would Help Country

10. 21st Century Health Care

11. AHRQ Priorities

12. Potential Future Directions: Health Care in 2025 All institutions and caregivers are members of integrated networks which must meet national standards for care Patient-centered care is considered the redesign of health care with patients rather than the redesign of care for patients There are no barriers for anyone to receiving appropriate health care

13. Comparative Effectiveness and the Recovery Act The American Recovery and Reinvestment Act of 2009 includes $1.1 billion for comparative effectiveness research: AHRQ: $300 million NIH: $400 million (appropriated to AHRQ and transferred to NIH) Office of the Secretary: $400 million (allocated at the Secretary�s discretion)

14. IOM Priorities for Comparative Effectiveness Research 100 recommendations listed in four groups of 25, ranging from highest to lowest priority A starting point for a sustained effort to conduct comparative effectiveness research, with priorities evolving as progress is made The highest priority quartile includes a recommendation involving medical homes �Compare the effectiveness of comprehensive care coordination programs, such as the medical home, and usual care in managing children and adults with severe chronic disease, especially in populations with known health disparities�

15. AHRQ�s Role in Comparative Effectiveness Using Information to Drive Improvement: Scientific Infrastructure to Support Reform Health technology assessment at the request of the Centers for Medicare & Medicaid Services Analyze data/options for Coverage with Evidence Development (CED) and post-CED data collection Provide translation of comparative effectiveness findings Promote and fund comparative effectiveness methods research Fund training grants focused on comparative effectiveness

16. Revitalizing Primary Care Growing popularity of the term �medical neighborhood� Primary care unconnected to subspecialty care, acute care/hospitals, community and public health resources, etc, will not reach potential for improving health and increasing value Revitalizing primary care will required new structures such as the medical home, paired with aligned reimbursement and a focus on the primary care workforce

17. AHRQ and the Patient- Centered Medical Home There are significant opportunities to address the primary care needs of Americans while encouraging primary care clinicians to use their expertise to help build truly patient-centered medical homes AHRQ is sponsoring a meeting July 27-28 to establish a policy relevant research agenda around the medical home A request for proposals was issued by AHRQ on Tuesday, 7/14, for projects involving health IT and the medical home

18. Comparative Effectiveness Research and Primary Care Comparative effectiveness research can be used to study the efficacy of delivery systems for primary care and the medical home It can assist with care coordination challenges in primary care and in managing patients with chronic diseases, especially in populations with known health disparities It can enhance patient engagement by promoting increased collaboration in decision making among patients, clinicians and providers

19. Comparative Effectiveness Funding Opportunities Opportunities for the field to become involved will be made available as soon as possible: To sign up for updates, visit http://effectivehealthcare.ahrq.gov To review AHRQ�s standing program and training award announcements http://www.ahrq.gov/fund/grantix.htm

21. Patient-Centered Primary Care Collaborative Stakeholders� Working Meeting July 16, 2009 Steve Wojcik Vice President, Public Policy National Business Group on Health

22. 22 What is Meaningful Health Reform? Major Reform Would Require More: Coordination, Less Fragmentation of Care Payment for Outcomes, Not for Volume Provider Accountability for Patient Health, Not Just for Treatment of Disease Coverage Based on Evidence and Effectiveness, Not On Other Factors

23. 23 Are We Headed Toward Meaningful Health Reform? Focus in Washington Almost Exclusively Now on Two Issues: Expanding Coverage, and Finding Ways to Pay for It Big Issues are Public Plan and Who/What to Tax Major Delivery and Payment Reforms Still Missing Real Solutions to Controlling Costs, Changing Delivery Not Yet in Legislation

24. 24 What We Need: Real Payment and Delivery Changes CBO (June 16,2009): �Large Reductions in Spending Will Not Actually Be Achieved without Fundamental Changes in the Financing and Delivery of Care.� �Without Meaningful Reforms, the Substantial Costs of Many Current Proposals to Expand Federal Subsidies for Health Insurance Would Be Much More Likely to Worsen the Long-Range Budget Outlook than to Improve It.�

25. 25 Why Primary Care Is Central to Meaningful Reform Patients with Ongoing Primary Care Provider Relationship Have Better Health Outcomes, Lower Costs When Managed Effectively by Primary Care Providers, Patients with Chronic Diseases Have Fewer Complications, Hospitalizations States with Higher Number of Generalist Physicians Per Capita Have Better Quality, Lower Costs 5% Increase in Primary Care Physicians Reduces Hospital Admission, Emergency Room Visits, and Surgeries

26. 26 How Do We Get There? Workforce Policy Reorganizing Health Care Delivery Payment Policy

27. 27 Health Reform Bills and Primary Care Economic Stimulus Law Gives Preference to Primary Care Providers for Federal HIT Technical Assistance House and Senate Finance Bills Increase Medicare Payments for Primary Care Providers Enhance and Expand Medical Home Pilots Boost Funding/Loan Assistance for Training of Primary Care Providers Senate HELP Bill Provide Grants and Other Support for Community-Based Medical Home Models Grants for School-Based Primary Care Clinics Create Office in HHS to Foster Primary Care Loan Assistance for Primary Care Education

28. 28 Transformation of Payment: Key Elements Eliminate Volume Incentives Recognize Value of Cognitive Services Reward Care Coordination Provide Incentives for Quality Reward Efficient Use of Technology Encourage Accountable Care Organizations/Medical Homes

29. 29 NBGH Primary Care Work Group Increase Awareness Among Employers of Crisis in Primary Care Advocate for Primary Care Reforms Use Market Leverage to Create Change Explore Models for Payment Reform Coordinate with Primary Care in the Community

30. 30 Employer Payment Policy Recommendations As Initial Step to Comprehensive Payment Reform, Increase FFS Payments for Primary Care Blended Reimbursement Bundled Episode Payments

31. 31 Employer Primary Care Initiatives Support Medical Home Pilots Work with Health Plans and Communities on Primary Care Explore Coordination of Services and Exchange of Information between Worksite Clinics and Primary Care Practices Participate in NBGH Primary Care Work Group and the PCPCC

32. Payment Policy and Primary Care Workforce: Implications for the Medical Home Eugene Rich MD Scholar in Residence Association of American Medical CollegesProfessor of MedicineCreighton University RWJ Health Policy Fellow 2006-07

33. Average Physician Income, 1969

34. Early Drivers of Specialized Medical Practice Higher specialist physician income health insurance coverage for hospital based services Increased specialist MD productivity not offset by fee reductions WWII codifies higher incomes for military MD specialists Hospital incentives to increase residency positions Residents provide after-hours coverage, increased hospital productivity and assistance to private physicians GI Bill education benefits provide for payments to hospitals for GME Residency positions increase from 5000 in 1940 to 25,000 in 1955 Medical Education Reform-Flexner Report, 1910 The ideal medical school would control a teaching hospital and would have a full-time faculty involved in basic and clinical research

35. Early Drivers of Specialized Medical Practice Factors that favor development of a medicine sub-specialty Prevalent chronic diseases Complex diagnostic technology Various treatment options Lack of simple curative therapy Large volume of scientific literature Third-party reimbursement

36. Medicare Physician Payment and Specialist Practice Carried forward fee payments developed to insure against expensive hospital-based illnesses Carried forward fee payments developed before better technology made procedures less time-consuming (and less costly to provide) Provided financial access to well compensated procedures for the likeliest candidates Provided financial access to specialty care at the time when specialized practice options were rapidly expanding

37. Physician Specialty as a Percentage of Total Active Physicians

38. Financial Barriers to Generalist Care US Fee-for-service payments provided no reward for primary care functions Continuity Comprehensiveness Coordination Accessibility Accountability

39. Financial Barriers to Generalist Care US Fee-for-service payments provided no reward for primary care functions Continuity?- only if openings Comprehensiveness?- Why? Coordination?- NO! Accessibility?- NO! Accountability?- To Whom?? Widespread visibility and access to specialists

40. % GDP for Health Care

41. The Primary Care Gatekeeper The policy vision � a financial rationale for continuous, coordinated, comprehensive, accessible, accountable generalist practice 1983 - Primary-care gatekeeper and cost control- the SAFECO experience, NEJM 1985- General Internist as Gatekeeper, J Eisenberg, Ann Int Med

42. % MD Graduates Choosing Generalist Careers (FM, GIM, GPEDs)

43. % MD Graduates Choosing Generalist Careers (FM, GIM, GPEDs)

44. 1999-2008: The Deconstruction of Primary Care into profit lines Continuity- �virtual� continuity provided by Health plans using their administrative data Comprehensiveness- direct access to specialized clinical programs with their own imaging facilities and surgical suites Coordination- national companies selling disease management services. Accessibility- Discount stores and pharmacy chains build sales thru quick access to care in �minute clinics Accountability- the �ownership society,� and �consumer-directed health care�-patients are accountable to chose from a smorgasbord of cleverly marketed health care services

45. Ongoing Problems with the Medicare Fee Schedule Relative Value Update Committee (RUC) and �overvalued� services Budget neutrality to fee schedule changes Practice Expense calculations Physician side-businesses (e.g. infusion centers, imaging centers, endoscopy centers, surgery centers)

46. % GDP for Health Care

47. Ave Offered Physician Income, (Pre-Bonus) 2008

48. Worsening comprehensive care failures Primary care physicians already felt �rushed�; More to do during a single visit now than in 1980�s MOST Medicare beneficiaries have multiple chronic diseases More drug combinations recommended for each disease More preventive services/early interventions More extensive documentation regulations DTCA

51. Congressional Advisors Unanimous on Need for Fundamental Change Congressional Budget Office Dec 2007 Growth in US Health Care Spending �Unsustainable� Government Accountability Office Feb 2008 Ample research� concludes that the nation�s over reliance on specialty care services at the expense of primary care leads to a health care system that is less efficient research shows that preventive care, care coordination for the chronically ill, and continuity of care�all hallmarks of primary care medicine�can achieve improved outcomes and cost savings. MedPAC March 2008 �Medicare�s FFS payment system does not� reward physicians who provide�care coordination� �We are especially concerned about the impact� on access to primary care services� � �medical home� programs� if designed carefully, may be a way to improve the value of physician and other health care services.�

52. Paying for Primary Care Functions: �Patient-Centered Medical Home� Joint Principles adopted March 2007- AAFP, AAP, ACP, AOA Medical Practice- meeting special qualifications Whole Person Orientation Care is Coordinated and Integrated Extra Quality and Safety infrastructure, HIT Enhanced Access

53. Changing payment for �medical homes� Improved incentives for �traditional� primary medical care? New payment for new medical home services? Technology-enhanced practice: patient tracking, disease registries, reminders, email communication, remote monitoring Patient engagement, informed decision-making The chronic care model and team care

54. SGIM/STFM/APA Medical Home Policy research agenda project Convene national researchers, major primary care professional organizations, representatives and evaluators of PCMH demonstrations, health care purchasers, payers, patient advocates, and relevant policy makers specific objective: Develop a policy research agenda to inform the ongoing development and implementation of the PCMH

55. SGIM/STFM/APA Medical Home Policy research agenda project Topics for �white papers� Practice Transformation Payment Reform and the PCMH Measuring and Operationalizing the PCMH Clinical, Satisfaction, and Quality of Care Outcomes of the PCMH PCMH connections to the Delivery System Workforce issues and training requirements