Patient Centered Primary Care (PCPC) The Time Has Come

1. Patient Centered Primary Care (PCPC) The Time Has Come Paul Grundy MD, MPH, FACPM, FACOEM Director, Global Well-being Services, February 2007

2. Healthcare Drivers Trend • Imaging • Specialty Rx & Pharmaco-genomics • Personal Medical Devices Technology • Supply drives demand • Cost insensitivity: expectations • Consolidation & litigation Price Waste • Over-utilization • Medical Errors • Nursing shortage • Specialization • Administrative costs & IT deficiency Labor 87% 73% • Disease burden & severity • Complexity of care Uninsured 59% 43% • Chronic disease burden & aging • Fertility Demography 25% 20% 15% 11% 12% 10% 7% 18% 4% 0% 14% 10% 7% 5% 3% Our Healthcare Environment: Where We Are

3. Outcomes: Long, Healthy & Productive Lives Access Quality of Care: Our Healthcare System: How Are We Doing Technology Health Systems Performance Domains Equity Efficiency US Health System Performance: National Scorecard

4. Health Plan Complexity -HDHP,-PPO -Tiered networks -HMO, EPO, DMA’s -Co-insurance, Co-Pays, OOP Maximums, Deductibles, Plan Maximum, -Centers of Excellences Technology Challenges Technology Challenges -Imaging -Biopharmaceuticals -Devices -Web Data Interpretation & Quality -Personal Health Records -Imaging -Biopharmaceuticals -Devices -Web Data Interpretation & Quality -Personal Health Records Health Accounts -Health Reimbursement Account -Health Savings Account -Flexible Spending Account -Medical Savings account -Long term Care Insurance Pharmacy & PBM’s Pharmacy & PBM’s -Mail Order Chronic Meds -Specialty Drugs -Tiered Formularies -Adherence & Management Pgms -Mail Order Chronic Meds -Specialty Drugs -Tiered Formularies -Adherence & Management Pgms Privacy Issues Privacy Issues Regulatory Agencies (FDA, EMEA, MHLW, WHO, DHHS, CDC) Regulatory Agencies (FDA, EMEA, MHLW, WHO, DHHS, CDC) Employer Programs Disease Management & Care Coordination • -SHPS, Matria, American Healthways, ActiveHealth, Alere, AirLogix,Focused Health, Life Masters, Q-Med, RMS, Health Plans -Integrated Disability -Wellness & Health Promotion -On Site Services, Clinics Patients Are Besieged Our Healthcare Environment: What’s Happening To Insured Patients Advocacy Groups -Unions -Demographic Groups: e.g. AARP -Consumer Groups -Patient Groups -Unions -Demographic Groups: e.g. AARP -Consumer Groups -Patient Groups

5. BIOTECH ERA MEDICAL TOURISM CONSUMERISM Patients: More Is On The Way DEMOGRAPHIC SHIFT MEDICAL TOURISM

6. Tiered Networks Cost > Quality Network Negotiations -Health Plans -Network Management firms -Hospitals Pay 4 Performance Prescription Drugs -PBM’s: MedCo Health, Caremark/APCS, Express Scripts., Aerna, Walgreens, MedImpact, Cigna -Specialty Pharmacies -Pharmacy Consulting firms • Medicare, Medicaid • BTE,Business Coalitions • NQF, NCQA • Health Plans, ETG’s Government Agencies & Employers CMS, States, NBCH, NBGH, PBGH, etc Disease Management & Care Coordination • -SHPS, Matria/Cor Solutions, American Healthways, ActiveHealth, Alere, AirLogix,Focused Health, Life Masters, Q-Med, RMS, Health Plans Physicians Are Under Assault Our Healthcare Environment: What’s Happening To Physicians Measurement & Reporting -Claims -HEDIS, NCQA, NQF, Proprietary Quality Ratings Interventions -Generic Substitution -Formulary Adherence -Prior Authorization -Dose Optimization & Limits -Medication Adherence -Utilization Management

7. What is Primary Care? First Contact & Access to Care • initial point of care for all medical needs • Accessible days, nights, weekends • Timely appointments Comprehensive • Accountable for addressing large majority of healthcare needs • Recruits other providers to care team as warranted by clinical care needs • Considers physical, psychological and emotional needs Continuity of Care • Develops sustained partnership with patients over long period of time • Sustains involvement in care with other providers and institutions • Follows through with patient communications Coordination of Care • Sources and arranges referrals and services with other providers • Coordinates decision making with healthcare team to promote best outcomes for patients • Coordinates communications with patients to promote patient understanding and participation Holistic • Person-centered to respect beliefs, preferences, psychological as well as physical needs • Engages family and community resources After:- Malcolm Peterson, ACP, IOM, AIM 1980;84:843-51 - IOM , National Academy Press, 1996; Starfield, B.: Millbank Memorial Fund, 2005

8. What is Patient-Centered Primary care? Patient Engagement • Recast role of clinicians to provide more counseling and advising • Provide timely access for patients to resources, information and tools • Assistance with self-care and behavior change • Use of personal health records and easy patient access to their medical records HIT & Clinical Information Systems • Enable: evidence-based care, practice-based learning and quality improvement • Utilization of disease registries, reminders/alerts to physicians and patients • Clinical decision support on diagnostic and therapeutic options • Facilitation condition management, adherence monitoring • eHR, eRx, on demand access to patient data, lab and imaging results Provider Transparency • Performance data disclosure and access • Discount and price disclosure • Patient and peer assessment reporting Systematic Patient Feedback • Ongoing, routine practice feedback from patients • Targeted improvement planning, measurement and reporting based on practice feedback After:- Davis K., Schoenbaum S.C., Audet A-M., A 2020 Vision of Patient-Centered Primary Care, Commonwealth Fund, 2005

9. Impacts • Primary Care Attributes • First contact • Continuous • Comprehensive • Coordinates care • Patient-focused & long term • Family & community orientationIncludes: family practice, internal medicine, pediatrics • Improves major health outcomes – supply primary care physicians (PCP) per 10,000 population • Reduced adult mortality: total, heart disease, stroke & cancer: an increase of 1 PCP/10,000 reduces overall mortality by 5.3% saving 127,617 lives • Reduced infant mortality & low birth weight • Reduced hospitalizations for ambulatory care sensitive diagnoses • Improves delivery preventive services: primary care attributes significantly associated with being up to date on: • Immunization, screening, health habit counseling • States with higher ratios PCPs have lower rates smoking, obesity • Improves outcomes and access to needed health services for poor: reduces the disparity in health outcomes of minorities and the poor • Adverse health effects of income inequality are reduced by access to primary care (e.g. overall mortality, infant mortality, low birth weight) • Reduces health care costs: ratio of PCPs per population is associated with • Lower hospitalization rates for total US and for Medicare beneficiaries • Lower costs of care for common illnesses compared to specialists • Lower total cost of health services, lower Medicare spending Why Do We Care at IBM About Primary Care

10. Primary Care Score vs. Health Care Expenditures, 1997 UK DK NTH FIN SP CAN AUS SWE JAP GER US BEL FR Starfield 10/00

11. . . . HI . . MN . . CT WA . ND MA . . . . NE . SD ID . OR CA . . ME . NH . . . AZ RI . . ID . . NM . MT . IA UT . NJ . . TN . . FL . WI KS NY . . TX AR . PA . MI DE KY . WV . . NC VA AL MD . IL MS . . NV . AK R=.54 P<.05 GA SC LA Primary Care and Life Expectancy State Level Analysis PC physicians/population associated with longer life expectancy. Shi et al. Income, Inequality, Primary Care and Health Indicators. Journal of Family Practice. April 1999 Starfield 03/02

12. Rates of Avoidable Adult Hospitalization for 6 Conditions and Family Physicians-Internists per 10,000 Population Source: Parchman & Culler, 2004

13. Physician Access: Went to the ER for Condition that Could Have Been Treated by Regular Doctor if Available 2005 Commonwealth Fund International Health Policy Survey Adults with Health Problems

14. Complexity of Care & Outcomes: Patients Reporting Any Error by Number of Doctors Seen in Past Two Years Percent 2005 Commonwealth Fund International Health Policy Survey Adults with Health Problems

15. Complexity of Care & Outcomes: Patients Reporting Care Coordination Problem by Number of Doctors Seen in Past Two Years (Percent) 2005 Commonwealth Fund International Health Policy Survey Adults with Health Problems

16. …the need for primary care is great and its growing • Prevalence rate of chronic disease is very high and it is rising • 45% of US population (120 million Americans) has a chronic medical condition • 50% of Americians with a chronic medical condition (60 million) have more than one chronic medical condition • Within 10 years, the number of Americans with at least one chronic medical condition will grow by 25% to 150 million • Older age population: growing rapidly and higher rates of chronic disease • By 2030, 20% of Americans will be over the age of 65 • 83% of Medicare beneficiaries have one or more chronic conditions • 23% have 5+ chronic conditions • Between 2000 and 2010 population over 85+ will increase 50% • 92% of adults 80+ have 1 chronic condition; 73% have 2+ conditions

17. …but Int. Medicine primary care physician supply is shrinking • Demand for internists will increase by 38% between 2000 and 2020 from 106,000 to nearly 147,000) • In 2003: • First year IM residents only 19% planned primary care careers • Third year IM residents only 27% planned to practice general IM down from 54% in 1998 • Aging internal medicine workforce: 35% of physicians nationwide are over the age of 55 • 2004 ACP study: after 10 years practice 21% IM primary care physicians leave practice versus 5% for specialists • High debt for medical education and declining compensation for primary care: • > 80% of graduating medical students carry debt • Median for private medical schools: $160k • Median for public medical schools: $120k • 5% have debt > $200k

18. …and the Family Medicine pipeline is shrinking Residency Positions and Number Filled by U.S. Medical School Graduates. Courtesy of:American Academy of Family Physicians, based on data from the National Resident Matching Program

19. % Change in Average Physician Income 1995-2003Adjusted for Inflation Physician Income Declines Most Severe for Primary Care1995-2003 Professional & Technical Workers 8 6 % Change Hrs. Direct Patient Care 4 2 0 -2 Medical Specialists $175K -4 -6 -8 All Physicians $168K Surgical -10 Specialists $225K Primary Care $121K -12 Center for Studying Health systems Change, Community Tracking Study, Tu & Ginsberg, no. 15, June 2006

20. Why IBM Came Directly To Primary Care Physicians: Transformation Through Partnership Global Well-being Services and Health Benefits (GWBS & HB) Corporate Policy: Expectation of Excellence in Employee Well-being • TransforMed Advance patient-centered care by transforming practice around: • Outcomes & patient safety • Open Access Scheduling • Electronic health records • Team approach to care • Advanced Medical Home • Primary care home for patients • Certification for office practices: evidence based guidelines & information technology to deliver patient centered care • Value and quality of care measured • Reimbursement reform 3

21. Trusting physician-patient relationships with technology enabled practice-based learning, clinical decision support and full patient engagement Smart Cards…..new payment models • Hospital events ....admission…benefits eligibility, billing… Physicians’ patient files EHR HTS EHR Personal Patient Information at Point of Care…Evidence-Based Medicine Guidelines genomics Integrating the Patient Centric Record EHR EHR Surgery, recovery, discharge records Expression Arrays EHR On Demand Patient Information • Contact data • Medical history • Secure, authorized access • Measure impacts of targeted interventions • Disease management support • Telemedicine Devices • Member relationship management Analysis of lab results

22. Patient-Centered Primary Care Pilot • Superb access to care. Patients can easily make appointments and select the day and time. Waiting times are short. E-mail and telephone consultations are offered. Off-hours service is available. • Patient engagement in care. Patients have the option of being informed and engaged partners in their care. Practices provide information on treatment plans, preventive and follow-up care reminders, access to medical records, assistance with self-care, and counseling. • Clinical information systemsthat support high-quality care, practice-based learning, and quality improvement. Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments. • Care coordination. Specialist care is coordinated, and systems are in place to prevent errors that occur when multiple physicians are involved. Follow-up and support is provided. • Integrated and comprehensive team care.There is a free flow of communication among physicians, nurses, and other health professionals. Duplication of tests and procedures is avoided. • Routine patient feedback to doctors. Practices take advantage of low-cost, Internet-based patient surveys to learn from patients and inform treatment plans. • Publicly available information. Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs.

23. Employer-Physician Summit: Primary Care

24. Patient Centered Primary Care (PCPC) The Time Has Come Paul Grundy MD, MPH, FACPM, FACOEM Director, Global Well-being Services, February 2007