Ronda Kotelchuck, Executive Director Primary Care Development Corporation

1. National Health Reform: The Primary Care Imperatives and Strategies for Addressing ThemPresentation to the Center for Family and Community MedicineColumbia University Medical Center Ronda Kotelchuck, Executive Director Primary Care Development Corporation Thursday, January 21, 2010

2. Introduction: The Problems Health Care Reform: The Primary Care Agenda Primary Care Expansion Primary Care Transformation A. Practice Redesign B. Health Information Technology Lessons and Reflections Overview

3. 1. Introduction: The Problems

4. Rising Cost and the Role of Chronic Illness • The rising cost of health care is unsustainable • Cost is driven by the rising rate of chronic illness. It: • Is the single largest cause of morbidity and mortality • Is the single largest driver of cost (accounts for 75% of all health expenses) • Has the heaviest impact on low income communities • Will grow more severe as population ages • Chronic illness is overwhelmingly preventable or primary care manageable. Prevention and management require a robust model of primary care.

5. Primary Care Today: Insufficient and Poorly Organized • Primary care capacity is insufficient: • 60 million Americans lack access to primary care • Half of primary care doctors plan to reduce or end their practices • Only 20 percent of medical students plan to practice primary care   • U.S. is expected to need 46,000 primary care doctors by 2025 • Most primary care is poorly organized and still practiced in an outdated mode. It is: • Reactive and episodic • Subject to long waits and delays • Uncoordinated • Inefficient

6. Study: US Lags Behind other Countries in Key Primary Care Indicators • Commonwealth Fund study of 11 countries (November 2009) – Australia, Canada, France, Germany, Italy, Netherlands, New Zealand, Norway, Sweden, UK, US • US 10th out of 11 in use of Electronic Medical Records (46% - ahead of Canada) • 10th of 11 in use of care teams (ahead of France) • Last in access to after-hours care • Least likely to have financial incentives for clinical outcomes

7. 2. Health Care Reform The Primary Care Agenda

8. Health Reform Will Drive the Need for Expanded Primary Care Capacity • Expanded insurance coverage will put millions of new customers into the healthcare market • Physician shortages will increase by 25% and workload by 29% over the next 15 years. • The Massachusetts experience: • 97% coverage • Patients wait months for appointments • 40% of family physicians are not accepting new patients • Record use of ER for non-emergencies

9. Rising Costs Will Drive the Need to Transform the Model of Primary Care • Growing evidence shows that primary care is effective in reducing costs, improving health outcomes and eliminating disparities • Employers, insurers and policymakers are looking to primary care as the new paradigm. • A new model of care is necessary, however, to achieve these objectives. • Innovations in practice have been afoot for years (practice redesign, evidence-based clinical protocols, etc.) • Now these are integrated into the concept of the Patient-Centered Medical Home (PCMH)

10. PCDC: Offering Strategies for Primary Care Expansion and Transformation • Non-profit organization founded in 1993 to address lack of primary care access in underserved communities • Premier public-private partnership focused on needs of safety net providers - community health centers, hospitals, special needs providers • Three areas of expertise • Capital Financing • Performance Improvement • Policy

11. 3. PCDC: Strategies for Expanding Primary Care Expansion

12. PCDC Primary Care Expansion Strategy Problem: • Lack of capital constrains growth of long-standing, dedicated providers of care to the underserved; further hampered by credit crisis Strategy: • Use public funds to leverage private investment • Provide favorable-term loans to catalyze construction of new, expanded and renovated sites, modernized facilities • Provide: • Technical assistance for facility development • Provide strong oversight to ensure successful project completion and long-term sustainability

13. Results • PCDC Capital Projects (partial list) • Total investments of $245 million for 78 capital projects in New York State • Created capacity for 550,000 new patients/1.7M visits annually • Leverage more than 5:1 private:public investment • Cornerstone of local economic development: 2,200 permanent jobs created; 4,400 with community multipliers • Facilities operating successfully, no defaults

14. Joseph P. Addabbo Family Health Center Queens, NY Before After $9.4 million for 22,000 SF new facility; increased patient visits by 40%

15. Callen-Lorde Community Health Center Chelsea After $9.3 million for relocation & expansionIncreased patient visits from 8,000 to 48,000 annually Before

16. Reflections on Capital Strategy for Expansion • Partnership among stakeholders is key • Creates a permanent community infrastructure • Relative ease of raising capital • Builds a baseline of knowledge and relationships that provide great foundation stones for other initiatives (e.g., transformation; policy) • Technical assistance is critical for organizations that have little experience or internal capacity for undertaking a complex, expensive, risky process • Offers a replicable model to address the capacity crisis that will follow national health reform

17. 4. PCDC: Strategies for Transforming the Primary Care Model

18. The Need for Transformation Origin: Initial focus on financial strength of borrowers New realization: Poor work processes… Cause much capacity to go unused Become important barrier to access Result in inefficiency and waste Undermine financial strength Demoralize staff and patients. Hallmarks of poorly organized processes: Long waits for appointments; lengthy cycle times; low productivity; high no-shows; staff-focused (rather than patient-focused) processes; poor customer service Discovery of the gap between what is possible and what is. What’s possible? Care that is safe, effective, patient-centered, timely, efficient and equitable (six Aims of the IOM’s Crossing the Quality Chasm) The promise of a new primary care model: the medical home

19. A Vision of Transformation:The Patient-Centered Medical Home • The medical home concept: • Continuity • Well organized (efficient) practice • Easy access: Same day appointments, 24/7 telephone access, alternative access • Responsibility for health outcomes • Panel management • Care coordination across settings • Decision support • Incorporation of evidence based practice (prevention, treatment, management) • Patient /family engagement • Formalization and the growth of a movement: • Principles agreed to by major professional associations • NCQA standards, measures, system of recognition • The promise: Better health outcomes, reduced disparities; lower health care cost

20. A Vision of Beyond the Medical Home:Integrated Delivery Systems/Accountable Care Organizations • Vertically integrated, comprehensive services • Responsible for total care of a population • Use of value-based payment (bundled or global payments) which: • Rewards quality and outcomes • Achieves savings • Examples: Kaiser, Mayo, Geisinger, Intermountain

21. Strategies for Transformation: PCDC Performance Improvement Programs Medical Home Recognition – Assist providers to achieve NCQA recognition and transformation (also 2 programs below) Practice Redesign – Improve access and efficiency by eliminating wait times--both for appointments and during the visit—increasing through-put (productivity), improving patient and staff satisfaction and increasing revenues. HIT Implementation and Meaningful Use – Adopt and integrate technology to improve quality, coordinate and manage care, engage patients and improve patient-provider communication. Other PCDC Performance Improvement Programs: Attracting and Retaining Patients Increasing Revenue Primary Care Emergency Preparedness

22. Focus on: System Design Implementation Measurable Results Staff Organized as Care Teams Building Client Capability Sustainability Use of: Change Teams Change Concepts & Tactics Coaching and Training Collaborative Learning Project Management Frameworks for Improvement Model for Improvement (IHI) Chronic Care Model (Ed Wagner) Medical Home Model Performance Improvement – PCDC Approach

23. A. Practice Redesign The Issues: Patient visits often average 2 to 3+ hours (for 15 minutes of actual face-time). Patients often wait 3-6 weeks for an appointment; instead go to the ER No shows run as high as 50-60%; providers overbook to make up Organizations operate well below capacity (25-35%) Redesign process is complex, resource-intensive, challenging for self-implementation Program Results: Trained 219 teams No show rates decrease by nearly 70% Appointment backlogs drop from an average of 21 to 0-5 days Providers able to hold 4-8 same-day appointments in daily schedule Cycle time reduced to an average of 51 minutes (50%+ reduction) Provider productivity increase of 33% Improved patient and staff satisfaction .

24. B. Implementation and Meaningful Use of HIT The Issues: Difficult, expensive, risky process Organizations with little experience or internal capacity, few resources Excessive, vendor-generated information; little ability to evaluate The Program:TA for all stages of HIT adoption (38 teams) HIT vendor selection and contracting (23 teams) Planning and readiness (11 teams) Internal capacity: team building, staff training, project management Design (workflow, decision support) Budgeting Implementation and go-live (6 teams) Effective use (Assure “meaningful use” compliance) Data reporting (Quality, compliance, panel management) (2 teams) Health information exchange (6 teams) Remediation (1 team)

25. The Challenge of the Next Five Years • 2 simultaneous, highly-interrelated, time-limited initiatives • Both improve care, provide financial incentives • NCQA medical home recognition: NYS Medicaid Incentive Pool • FFS: $5.50/$11.25/$16.75 per visit for Levels 1/2/3 • Managed Care: $2/$4/$6 pmpm for Levels 1/2/3 • Level I phased out after December 2012 • HIT meaningful use compliance • Medicaid: Up to $63,750 over 6 years • Medicare: Up to $48,000; penalties beginning in 2015 • Both are complex, expensive, a challenge for self-implementation – Current focus on PCDC program development

26. 5. Lessons & Reflections

27. 5. Reflections: The Nature of Organizational Change • The under-appreciation of implementation • People know what needs to be changed. They lack knowledge of how to change • Transforming the model of primary care requires major, thorough-going organizational and cultural change. • Myths: • It can been done “fast and cheap” • It’s a project. Once done, we can move on to other things. • It can be delegated from the top • The importance of technical assistance, willingness to invest in the change process • The under-appreciation of everyday operations • Practice redesign, HIT as preconditions for clinical improvements, quality

28. Reflections on Safety Net Settings • Private practice • Strong on continuity, access and efficiency • Isolation raises concerns about quality, coordination • Setting is simpler, change is easier • Small size, spare resources pose a challenge to implementing HIT, PCMH • Community Health Centers • Continuity, access, efficiency not assured • FQHCs offer robust model, many PCMH functions, experience in quality improvement • Special Needs Providers • Already offer a “care home,” instinctually understand medical home • Hospital OPDs • Broad scope of service available (specialties, ancillaries) • Continuity, access, efficiency present challenge in teaching environment • Primary care is not the institutional focus or priority

29. Reflections: PCDC as a Model for Expanding and Transforming Primary Care • Leverages private investment for small investment of public resources; availability of capital (relative to expense) • Produces measurable, sustainable outcomes, able to reach scale; builds lasting community infrastructure; delivers important community development benefits • Works across wide range of provider types (community health centers, hospitals, private practitioners) • Is adaptable to localities, states, foundations • Offers excellent platform upon which to build additional programs and services • Value of an organization dedicated solely to primary care • Builds a strong community of interest in the success of primary care.

30. Contact Ronda Kotelchuck Executive Director Primary Care Development Corporation Phone: (212) 437-3917 E-Mail: rkotelchuck@pcdcny.org Website: www.pcdcny.org