RPA 2009 Annual MeetingRPA 2009 Annual Meeting

Jeffrey P. Harris, MD, FACPJeffrey P. Harris, MD, FACPJeffrey P. Harris, MD, FACPJeffrey P. Harris, MD, FACP

Patient Centered Medical Home Patient Centered Medical Home

March 23, 2009March 23, 2009

Three Commonly Posed Questions:

1. Why does the ACP, with nearly equal numbers of general internists and subspecialty internists members, advocate for a system that appears more beneficial to primary care physicians?

2. How will my practice and my patients' experiences change?

3. Why should subspecialists support this model?

PCMH/The Central Hub of Care

• why is it needed

• what must it provide

• how might it be funded

• where should it be

Escalating CostsInternational Comparison of Spending on Health, 1980–2004

0

1000

2000

3000

4000

5000

6000

7000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Data: OECD Health Data 2005 and 2006.

0

2

4

6

8

10

12

14

16

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Average spending on healthper capita ($US PPP)

Total expenditures on healthas percent of GDP

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

EFFICIENCY

4

Total outlays in billions

$454 $486 $514$567 $568

$636 $681$729

$814 $850 $887

$0

$200

$400

$600

$800

$1,000

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Projected Medicare Outlays, 2008-2018

NOTE: Numbers have been rounded to nearest whole number. SOURCE: Kaiser Family Foundation, based on Congressional Budget Office, The Budget and Economic Outlook: An Update, January 2008.

16% 16% 16% 17% 17% 18% 18% 19% 20% 20% 20%

3% 3% 3% 3% 3% 3% 4% 4% 4% 4% 4%

Share of:Federal BudgetGross

Domestic Product

Medicare Beneficiaries and The Number of Workers Per Beneficiary

79

62

47

19

40

34

20

1966 1970 1990 2000 2010 2020 2030

Millions of beneficiaries

4.0

2.4

2.9

3.7

2000 2010 2020 2030

Number of workers per beneficiary

SOURCE: Kaiser Family Foundation, based on 2001 and 2008 Annual Reports of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.

USA: LESS EFFICIENTAdministrative and Insurance Costs as %

of National Health Expenditures 2003

2.60%

5.60%

4.80%4.20%

4.00%3.30%

2.10%

7.30%

1.90%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

FR

JA

P

CA

N

UK

NT

H

AU

ST

SW

Z

GE

R

US

A

Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006. www.commonwealthfund.org

Life Expectancy at Birth in 2005Life Expectancy at Birth in 2005

77.8 77.9

79 79 7979.4 79.4

80.2 80.3

80.9

81.3

82

75

76

77

78

79

80

81

82

USA DEN GER UK NZ BEL NETH CAN FR AUST SWZ JAP

Source: OEDC Data, 2007

CriteriaCriteria: Overall Mission to Achieve Long, Healthy : Overall Mission to Achieve Long, Healthy and Productive Livesand Productive Lives

Infant Mortality per 1000 Births (2005)

3.6 3.7 3.9 4.2 4.45 5.1 5.1

6.8

4.9

2.8

0

2

4

6

8

JAP

FR

BEL

GER

SW

Z

DEN

NET

H

AU

ST

NZ

UK

USA

Source: OEDC Data, 2007

USA: MORE ERRORSUSA: MORE ERRORSDeaths Due to Surgical or Medical Mishaps Deaths Due to Surgical or Medical Mishaps

per 100,000 Population in 2004per 100,000 Population in 2004

0.7

0.6

0.5 0.5 0.5

0.4 0.4

0.2 0.2

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

United

States

Germany Canada France United

K ingdom

Australia OECD

Median

J apan Netherlands

a2003b2002

ab

b

bb

b

Source: The Commonwealth Fund, calculated from OECD Health Data 2006. Cylus J and Anderson GF. Multinational Comparisons of Health Systems Data, 2006

Buyers’ remorseBuyers’ remorse

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

Primary Care Associated with Primary Care Associated with Decreased CostsDecreased Costs

• According to the According to the Center for Evaluative Clinical Center for Evaluative Clinical Sciences at DartmouthSciences at Dartmouth, for patients with severe , for patients with severe chronic diseases, those who live U.S. states that chronic diseases, those who live U.S. states that relied more on primary care have:relied more on primary care have:– Lower Medicare spending (inpatient reimbursements and Part Lower Medicare spending (inpatient reimbursements and Part

B payments)B payments)– Lower resource inputs (hospital beds, ICU beds, total Lower resource inputs (hospital beds, ICU beds, total

physician labor, primary care labor, and medical specialist physician labor, primary care labor, and medical specialist labor)labor)

– Lower utilization rates (physician visits, days in ICUs, days in Lower utilization rates (physician visits, days in ICUs, days in the hospital, and fewer patients seeing 10 or more the hospital, and fewer patients seeing 10 or more physicians)physicians)

– Better quality of care (fewer ICU deaths and a higher Better quality of care (fewer ICU deaths and a higher composite quality scorecomposite quality score

Dartmouth Atlas of Health Care, Variation among States in the Management of Severe Chronic Illness, 2006

States with red circles have PC/Specialty Ratio of < 1.0States with green circles have PC/Specialty Ratio of >1.45

[In the last two years of life]

Dartmouth atlas

Quality/Cost Impact

Primary Care Score vs Health Care Expenditures 1997

Source: The Commonwealth Fund, Data from B. Starfield, “Why More Primary Care: Better Outcomes, Lower Costs, Greater Equity,” Presentation to the Primary Care Roundtable: Strengthening Adult Primary Care: Models and Policy Options, October 3, 2006. Quality/Cost Impact

OECD = Organization for Economic Cooperation & DevelopmentPYLL = Potential years of life lost

HPPC Examined Health Care in the USA HPPC Examined Health Care in the USA and Systems in 12 Other Countriesand Systems in 12 Other Countries

LessonLesson: High performing systems encourage : High performing systems encourage patients to be prudent purchasers and engage in patients to be prudent purchasers and engage in

healthy behaviorshealthy behaviors

• Cost-sharing Cost-sharing with co-payment schedules based with co-payment schedules based on incomeon income can help restrain costs while assuring can help restrain costs while assuring that poorer individuals have access that poorer individuals have access

• Incentives to encourage personal responsibility Incentives to encourage personal responsibility can be effective in influencing healthy behaviors, can be effective in influencing healthy behaviors, improved health outcomes and responsible improved health outcomes and responsible utilization, without punishing people who fail to utilization, without punishing people who fail to adopt recommended behaviors or lifestyles adopt recommended behaviors or lifestyles

Belgium

France

Japan

New Zealand

Switzerland

Australia Belgium Japan

New Zealand Netherlands Switzerland

Taiwan

Lesson: Lesson: High performing systems High performing systems measure their own performancemeasure their own performance

• Performance measures, Performance measures, financial incentives linked to financial incentives linked to quality, and active monitoring quality, and active monitoring of performance are key of performance are key elements of high performing elements of high performing systemssystems

Australia

New Zealand

United Kingdom

LessonLesson: Primary care is : Primary care is thethe foundation foundation of high performing delivery systemsof high performing delivery systems

• Societal investment in medical education can Societal investment in medical education can help achieve a well-trained workforce with the help achieve a well-trained workforce with the right proportion of primary care physicians and right proportion of primary care physicians and specialists and is large enough to assure accessspecialists and is large enough to assure access

• Investment in primary and preventive care can Investment in primary and preventive care can result in better health outcomes, reduce costs, result in better health outcomes, reduce costs, and help assure an adequate supply of primary and help assure an adequate supply of primary care physicians care physicians

• These efforts can be enhanced by assuring that These efforts can be enhanced by assuring that all residents have equitable access to a personal all residents have equitable access to a personal physician through a patient-centered medical physician through a patient-centered medical home modelhome model

France Germany

United Kingdom

Australia, Canada, Denmark

France NetherlandsNew Zealand Switzerland

UK

Denmark

LessonLesson: The best payment systems : The best payment systems recognize the value of care coordinated by recognize the value of care coordinated by

primary care physiciansprimary care physicians• Effective payment systems:Effective payment systems:

– Provide adequate payment for primary Provide adequate payment for primary care servicescare services

– Create incentives for quality Create incentives for quality improvement and reporting improvement and reporting

– Recognize geographic or local payment Recognize geographic or local payment differencesdifferences

– Provide incentives for care coordination Provide incentives for care coordination

Canada Denmark Germany

United Kingdom

Belgium

United Kingdom

Denmark Netherlands

Lesson: Lesson: High performing systems invest in High performing systems invest in HIT, have uniform billing, and lower HIT, have uniform billing, and lower

administrative costsadministrative costs• Adoption of a uniform billing and Adoption of a uniform billing and

electronic processing of claims improves electronic processing of claims improves efficiency and reduces administrative efficiency and reduces administrative expensesexpenses

• An inter-operable health information An inter-operable health information infrastructure can enable physicians to infrastructure can enable physicians to obtain instantaneous information at the obtain instantaneous information at the point of medical decision-making and point of medical decision-making and enhance electronic communications enhance electronic communications among treating health professionals among treating health professionals

Germany

Canada

Taiwan

United Kingdom and most others

Denmark

Taiwan

Netherlands

Interest in Entering Primary Care has been Interest in Entering Primary Care has been Declining Among Graduating SeniorsDeclining Among Graduating Seniors

(Percentages 1999-2006)(Percentages 1999-2006)

0

2

4

6

8

10

12

14

1999 2000 2001 2002 2003 2004 2005 2006

GIMIM SSFPPED

Source: Association of American Medical School Graduation Questionnaires http://www.aamc.org/data/gq/allschoolsreports/2006.pdf

Bodenheimer, T. et. al. Ann Intern Med 2007;146:301-306

The Primary Care—Specialty Income Gap

Patient-Centered, Physician-Guided Care

Adapted from:Defining Primary Care: An Interim Report, Institute of Medicine 1994

Physician Patient

Practice Family Team

Integrated CommunityDeliverySystemorVirtualTeam

Core of Team-Based Care

NP/PARN/LPNMedical AssistantCare CoordinatorOffice StaffNutritionist/EducatorPharmacistBehavioral HealthCase ManagerCommunity resourcesDM companiesOthers…

Immediate familyExtended familyFriendsNeighbors

What must it provide/Joint Principles

patient centered

personal physician

team approach

whole person

• preventive/acute/chronic/end of life

longitudinal care

coordinated care

high quality and continuous quality improvement

navigation of a complex system

PCMH/Payment

1) “Bundled Care” Coordination Fee

▪ Physician/non-physician work outside of face-to-face visits (e.g. email, telephone/group visits

-Promoting efficiency rather than volume-based care

▪ System infrastructure (e.g. HIT)

-Encourage coordination of care

▪ Risk adjusted

-Remove incentives to avoid complex or costly patients

PCMH/Payment

2) Visit based fee-for-service

• Incentive to physician to see patients in office when appropriate

3) Performance based component

• Recognize achievement of quality and efficiency

Potential New Payment Codes

Care plan oversight for specified condition

• Communicate with provider of treatment

• On-going review of patients’ medical status/labs

• Care plan modification

Physician e-mail/telephonic consultations

Training and follow up of patient self management by physician/nurse

Health Care Utilization & Primary Care

• For population of 775,000, an increase from 35% to 40% primary care physicians could:– Reduce inpatient admissions by ~2500/year

• At approximately $9000/admission = $23M

– Reduce ED utilization by 15,000 visits/year– Reduce surgery by about 2500 cases/year

*Kravet, S et al: Health Care Utilization and the Proportion of Primary Care Physicians.

Amer J of Medicine, 2008; 121:142-148.

Three Commonly Posed Questions:

1. Why does the ACP, with nearly equal numbers of general internists and subspecialty internists members, advocate for a system that appears more beneficial to primary care physicians?

2. How will my practice and my patients' experiences change?

3. Why should subspecialists support this model?

Why is the ACP Advocating for Stronger Primary Care and the PCMH Model:

• Extensively reviewed data from this country and abroad

• Data compellingly suggest: Better outcomes and reduced costs by expanding primary care

How Might the PCMH Benefit Primary Care Physicians:

• Narrowing the earnings disparities– payment for care coordination – performance-based component to recognize

quality and efficiency – visit-based fee-for-service payment to incentivize

physicians to see patients in the office

• More time to spend with chronically ill patients

 

How Might the PCMH Benefit Patients:

• Innovative scheduling systems to minimize delays in getting appointments,

• Non-urgent medical advice by e-mail and telephone,

• Same-day care with PCMH-based non-physicians for less complex patient issues,

• Group teaching of patients with chronic diseases.

How Might the PCMH Benefit Patients:

• Time for coordinating care with family and other clinicians

• Evidenced-based point-of-care support tools, and

• Better health information technology (HIT) to efficiently coordinate all sources of the patient's care within the community and track quality and patient satisfaction measures to promote continuous improvement.

How Might the PCMH Benefit Subspecialists?

• May head a medical home

• New billing codes

• Fewer hassles

• Better referrals

• Improved quality of practice

• Efficient spending