IF YOU DON’T HAVE A PRIMARY CARE STRATEGY, YOU ARE NOT

PAYING ATTENTION Hospital Council of Northern and Central California

May 17, 2013 Kevin Grumbach, MD

Center for Excellence in Primary Care Department of Family & Community Medicine

University of California, San Francisco

Are you a hospital or a health care delivery system?

3 Care

1 Care

2 Care

Medical Neighborhood

Medical Home

This is a health system

Tom Daschle, testifying to Senate Health Committee, Jan 2009: “Every country starts at the base of the pyramid with primary care, and they work their way up until the money runs out. We start at the top of the pyramid, and we work our way down until the money runs out…And so we have to change the pyramid. We have to start at the base.”

3 Care

2 Care

1 Care

A Strong Foundation of Primary care is Essential to: • Achieving the triple aims of

– Better and more equitable health care – Better health outcomes – Lower costs

• Succeeding as an ACO in a population

health and value-based health care framework

– “Ample research concludes in recent years that the nation’s over reliance on specialty care services at the expense of primary care leads to a health 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 better health outcomes and cost savings.”

3

2

1

Source: Baicker & Chandra, Health Affairs, April 7, 2004

Source: Baicker & Chandra, Health Affairs, April 7, 2004

The President Wants You (to be a PCP)!

“It used to be that most of us had a family doctor; you would consult with that family doctor; they knew your history, they knew your family, they knew your children, they helped deliver babies. How do we get more primary physicians, number one; and number two, how do we give them more power so that they are the hub around which a patient-centered medical system exists, right? ” June 8, 2010, Town Hall with Seniors

But the Primary Care Foundation in the US is Crumbling

• Plummeting numbers of new physicians entering primary care and burnout among PCPs

• Growing problems of access to primary care and “medical homelessness”

• Dysfunctional systems that are not delivering the goods in primary care

Bodenheimer T. N Engl J Med 2006;355:861-864

Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates

Bodenheimer T. N Engl J Med 2006;355:861-864

Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists

Dr. Katherine J. Atkinson of Amherst, Mass., has a waiting list for her family practice; she has added 50 patients since November.

In Massachusetts, Universal Coverage Strains Care

April 5, 2008

Partly a Payment Issue

The Widening Physician Payment Gap

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

$350,000

$400,000

$450,000

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

Year

Ann

ual I

ncom

e

Diagnostic Radiology

Orthopedic Surgery

Primary Care

Family Medicine

Source: Robert Graham Center

Ebell, M. H. JAMA 2008;300:1131-1132.

Percentage of Positions Filled With US Seniors vs Mean Overall Income By Specialty

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

Relative Income FM vs Specialties (MGMA) Preference for PC (GQ)

2008 Incomes:FM $180,000Spec $340,000

FM preferences increase from 4.8% to 6.4% between 2008-9

Ratio of Average US

Primary Care

Physician Income to Average Specialty Income

Percent of Graduating US Medical

Students Who Plan Careers in Primary

Care Source: Council on Graduate Medical Education. Twentieth Report: Advancing Primary Care, December 2010.

Partly a Medical Education and Medical Culture Issue

Feedback to UCSF Students About Their Interest in Family Medicine

“Why would you want to be a family doctor? They’re basically glorified triage nurses.”

“But you’re too intelligent for family practice!”

“Family practice is an evil plot by Congress!”

Source: Fam Med, 1995

FP

Partly a Systems Issue

The New Math of the 15 Minute Primary Care Visit

• A primary care physician with a panel of 2500 average patients would spend: – 7.4 hours per day to deliver all recommended

preventive care [Yarnall et al. Am J Public Health 2003;93:635]

– 10.6 hours per day to deliver all recommended chronic care services [Ostbye et al. Annals of Fam Med 2005;3:209]

Primary Care Practice Transformation

• Patient-Centered Medical Home (PCMH)

• Advanced Primary Care • High Performing

Primary Care

Building Blocks of High-Performing Primary Care The Share-the-CareTM Model

http://www.pcpcc.net/content/pcmh-outcome-evidence-quality

Review of Recent Evidence on PCMH Outcomes

• 14 different initiatives – >1 million patients, 1000s of medical practices – 5 Integrated delivery systems

• Group Health, Geisinger, HealthPartners, Intermountain, VHA – 3 Private health plan sponsored initiatives

• BCBS South Carolina, BCBS North Dakota, Metropolitan Health Networks Florida

– 2 Medicaid state initiatives • North Carolina, Colorado

– 4 Other models

Findings Are Consistent Across These Studies

• Quality of care, patient experiences, care coordination, and access are demonstrably better.

• Reductions in ED visits and hospitalizations produce net savings in total costs per patient.

Examples of Cost Outcomes • Group Health Cooperative: 5% ↓ $PMPM • Geisinger: 7% ↓ $PMPM • VA: $593 ↓ cost per patient with COPD • BCBS South Carolina: 6.5% ↓ $PMPM • Metropolitan Health Networks: 20% ↓ $ per patient • North Carolina Medicaid/SCHIP: Cumulative

savings of $974.5 million over 6 years (2003-2008) • Colorado Medicaid: $215 ↓ cost per child per year

Case Study of Group Health Cooperative of Puget Sound

• Patient Centered Medical Home model piloted at one site in 2007 – Avg PCP panel size reduced from 2327 to 1800 – Longer face-to-face visits and scheduled time

for phone and email encounters – Increased team staffing and teamwork – HIT – Panel management

Group Health PCMH Pilot: Controlled Evaluation 12 Month Outcomes

• Improved continuity of care • Better patient experiences (6 of 7 measures) • Better composite quality of care score • Reductions in ED visits and Ambulatory

Care Sensitive Hospitalizations • No difference in total costs at year 1 (lower

total costs by year 2) Source: R Reid et al. Am J Managed Care 2009;15:e71

Group Health PCMH Pilot: Effect on Clinic Staff

30.0%34.5% 33.3%

9.7%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Control Sites PCMH Site

Percent with High Level Emotional Exhaustion

Baseline12 Months

p=.02

Health Affairs Sept, 2012

WellPoint Launch in 2012 of Patient-Centered Primary Care Strategy

• “Payment innovation through these three pilots demonstrated preliminary evidence of improvement in the quality and affordability of care. As a result, after initial evaluation of the pilots, WellPoint created its Patient-Centered Primary Care strategy to expand the reach of concepts relating to the patient-centered medical home.”

Circle

Of

Participants

CAPG Military Health System

Community Clinics

Academic Centers

Primary Care

Academies

Health Plans

Employers

Purchasers

State & Federal

Government

California Advanced Primary Care Institute

• Pipeline: Paving the way for upcoming medical students, nurse practitioners, physician assistants, pharmacists

• Practice Redesign: Re-engineering primary care to PC-MH model of care (team-based)

• Payment: Creating payer collaboratives to support primary care (aligned incentives)

• Policy: Providing focus, education and act as trusted resource to advancing primary care

California Advanced Primary Care Institute

The Four P’s

Patient & Family

Advanced Primary Care Under Patient-Centered

Medical Home

Medical Group & Enterprise Level Activities

Accountable Care Organization

Care Transformation Model Clinical Integration

Care Transformation Model Clinical Integration

Patient & Family

• Personal Health Record • Patient Portal • Health Risk Assessment • Patient Engagement &

Activation

Care Transformation Model Clinical Integration

Patient & Family

Advanced Primary Care Under Patient-Centered

Medical Home • Prevention & Wellness • Point of Care Analytics /

Gaps in Care • Population Management &

Chronic Care Registries • Generic Prescribing • Team-Based Care (NPs,

PAs, Pharmacists)

• Cost Effective Utilization of Services (SCP, Ancillary)

• Access, Same Day Appointments, e-Visits

• Patient Satisfaction & Loyalty • Provider & Office Staff

Satisfaction

Care Transformation Model Clinical Integration

Patient & Family

Advanced Primary Care Under Patient-Centered Medical Home

Medical Group & Enterprise Level Activities

• PCP/SCP Incentives • Pay for Performance • Hospitalists, Post Discharge

Follow-Up • Care Management (Acute,

Chronic, Inpatient, SNF) • Health Coaching (Shared

Decision Making)

• ER Avoidance Programs • Urgent Care • End of Life (Palliative Care) • Transitions of Care • Behavioral & Mental Health

Coordination of Services

Care Transformation Model Clinical Integration

Patient & Family

Advanced Primary Care Under Patient-Centered Medical Home

Medical Group & Health Care System Enterprise Level Activities

Accountable Care Organization Hospitals • Service Line Integration • Medical Staff Alignment • Incentives for Efficiency • Quality (SCIP, Leap Frog) • Safety • Outcomes & Evidence Based Medicine

• Call Coverage

Skilled Nursing Facilities • SNFists • On-site Case Management • Efficiency Rating Systems “Preferred Facilities”

Ancillary Services • Free-Standing ASC & Diagnostic Testing Centers

Home Care • Home Safety Visits • Post Discharge Visits

• Home Health Hospice • Home Palliative Care

DME • Integration & Oversight by Care Management

Patient & Family

Advanced Primary Care Under Patient-Centered Medical Home

Medical Group & Enterprise Level Activities

Accountable Care Organization Hospitals • Service Line Integration • Medical Staff Alignment • Incentives for Efficiency • Quality (SCIP, Leap Frog)

•Safety

Skilled Nursing Facilities • SNFists • On-site Case Management • Efficiency Rating Systems

“Preferred Facilities” Ancillary Services • Free-Standing ASC

& Diagnostic Testing Centers

Home Care • Home Safety Visits • Post Discharge

Visits • Home Health

Hospice • Home

Palliative Care

• PCP/SCP Incentives • Pay for Performance • Hospitalists, Post Discharge

Follow-Up DME • Integration &

Oversight by Care Management

• Outcomes & Evidence Based Medicine

• Call Coverage • ER Avoidance Programs • Urgent Care • End of Life (Palliative Care)

• Personal Health Record • Patient Portal • Health Risk Assessment • Patient Engagement &

Activation

• Prevention & Wellness • Point of Care Analytics /

Gaps in Care • Population Management &

Chronic Care Registries • Generic Prescribing • Team-Based Care (NPs,

PAs, Pharmacists

• Cost Effective Utilization of Services (SCP, Ancillary)

• Access, Same Day Appointments, e-Visits

• Patient Satisfaction & Loyalty • Provider & Office Staff

Satisfaction

• Care management (Acute, Chronic, Inpatient, SNF)

• Health Coaching (Shared Decision Making)

• Transitions of Care • Coordination of

Behavioral & Mental Health Services

Care Transformation Model Clinical Integration

What is your Primary Care Strategy?

• Medical group model • PCP compensation • Support for primary care practice

transformation • Clinical integration in a cohesive medical

neighborhood